This is a case study assignment that will be used to evaluate your clinical thinking skills in several ways. This case unfolds much as it would in real life. The data is presented as it might during a typical client encounter. We want to see proper medical diagnostic statements for medical diagnoses because for many students, this is a new skill. The first two questions should be answered with only the data provided up to that point. This type of format has two purposes: 1) to help lead you through the diagnostic thinking process as it happens in real life, and 2) so we can evaluate your thinking process throughout the client encounter and not just at the end of it. There are questions in total: again, only answer the questions with the data and decisions you have made up that point. Overall, this paper is to demonstrate your approach to the patient and his condition(s). It is not a paper about the condition itself, so do not include unnecessary points on the pathophysiology unless asked.
Jim is a 54-year-old Caucasian man. Jim is obese and has not seen a health care provider in 6 years. He states that until 3 months ago he was feeling fine but over the last couple of months, he has developed skin rashes in the folds of his skin and another type of rash on his shins. He admits to being fatigued most days. He currently takes no medication.
1) Based on the information provided thus far, what are your potential diagnoses? Name 3 and provide your confirming and refuting evidence for each one. You may use a table.
2) What else would you like to ask Jim? (focused system review)
3) What physical assessment components are relevant to your differential - What will you look for and why?
4) Name these rashes, the treatment you would order, and describe your thoughts as to the cause of these rashes relative to this client (etiology).
5) Based on the history and physical findings, what, if any, diagnostic testing would you do? Include your rationale. You may use a table
6) What is the significance of the lab results
7) What are the priorities for care today and what will you prescribe?
8) What are the short-term management goals for Jim? Provide rationale for your decisions