Case Analysis Tool Worksheet
Student’s Name:
I. Epidemiology/Patient Profile
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Mr. Smith is a 53-year-old Caucasian male who presented to the clinic complaining of swelling and pain in his left lower extremity. Medical history of obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use. He appears to be a good historian. |
II. Prioritized Cues from Hx and PE.(Do not include lab, x–ray, or other diagnostic test results here.)
• Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem.
• Tier 2: These are cues of intermediate importance (list only positive cues).
• Tier 3: Of least importance (list only positive cues).
Tier 1 Tier 2 Tier 3
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Swelling and pain in his left lower extremity for 4 days |
Denies of fever, chest pain, shortness of breath. |
Staying in public housing with family |
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Pain worsen with weight bearing and movement |
Dorsalis pedis 2+ |
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Neuropathy of lower extremity |
Posterior tibial pulses are palpable bilaterally |
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Left foot plantar surface ulceration noted. |
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Left calf circumference is larger than right by 3.5 cm |
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Smoker 1.5 packs/day |
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Medical history of obesity, type 2 diabetes, hypertension, hyperlipidemia |
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Left leg Erythematous and edematous |
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Tenderness of the left leg along the distribution of deep venous system. |
III. Problem Statement
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Mr. Smith is a 53-year-old Caucasian male who presented to the clinic complaining of 4 days worsening swelling and pain in his left lower extremity. The patient reports pain not relieved by rest and aggravated with standing up or movement. Swollen and erythematous of bilateral lower extremities, and left calf circumference is larger than right by 3.5 cm. Left foot plantar surface ulceration noted. Medical history of obesity, type 2 diabetes, hypertension, hyperlipidemia, and 1.5 packs tobacco use a day. He appears to be a good historian. |
IV. Differential Diagnosis
Based on what you have learned from the history and physical examination, list up to 3 diagno
Aquifer Essay Title
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Aquifer Essay Title
The introduction should be a paragraph that provides a brief overview of the case and main diagnosis with rationale and supporting evidence. You do not need to discuss pathophysiology or summarize the entire case. The entire paper should be between one and three pages long.
Differential Diagnoses
This section will identify your two differentials with the rationale and supporting evidence. Also explain why these differentials were not the main diagnosis.
Diagnostics
Identify the lab, radiology, or other tests needed for the main diagnosis with supporting evidence. Do not include excessive or non-pertinent testing.
Treatment, Education, and Follow-Up
This section should include the elements of an initial treatment plan for the main diagnosis. It should include medication names, dosages, frequencies; patient/family education; appropriate follow up plan; and hospitalizations and consults when appropriate.
References
The supporting evidence for this paper should be derived from at least two primary sources (not Medscape, UpToDate, Epocrates, etc.), including published clinical guidelines or peer-reviewed professional journals that are NOT textbooks. Supporting evidence should be published within the past 5 years, or 10 if the guidelines have not been updated. References should be in APA format. Refer to the APA 7 Manual for specific formatting requirements.
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