CASE STUDY 2

GRADING SHEET FOR NUR 631 WRITTEN CASE STUDY

Student Name: CCS# _1__

HISTORY DATA- 40 points HX pts____

Chief Concern (CC) (8) ____

Complete History of Present Illness (HPI) (12) ____

Pertinent PMH (meds, allergies, social risks) (4) ____

Review of Systems (Case data documented appropriately) (12) ____

Family History (with genogram) (4) ____

PHYSICAL EXAM - 40 points PE pts_____

Case data appropriately documented in FULL PE

DIFFERENTIAL DIAGNOSIS - 10 points DD pts____

List 3 Differentials to explain primary problem (3@1ea=3) ____

Give a brief pathophysiologic description of each DD: (3)

Etiology ____

Usual clinical findings or features ____

Pertinent positives/negatives listed to support primary DD (2) ____

List additional history questions to support primary DD (1) ____

List additional physical findings to support primary DD (1) ____

PLAN OF CARE -5 points Plan pts___

(specific treatments including meds - be specific with doses, times)

Pharmacologic (2) ____

Non Pharmacologic (1) ____

Patient Education (1) ____

Follow Up (1) ____

*Neatness, typed, submitted on time, appropriate format,

use of appropriate terminology, references - 5 points Form pts___

Total points _____