In order to write a case study paper, you must carefully address a number of sections in a specific order with specific information contained in each. The guideline below outlines each of those sections.

Section

Information to Include

Introduction (patient and problem)

• Explain who the patient is (Age, gender, etc.)
• Explain what the problem is (What was he/she diagnosed with, or what happened?)
• Introduce your main argument (What should you as a nurse focus on or do?)

Pathophysiology

• Explain the disease (What are the symptoms? What causes it?)

History

• Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
• Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)

Nursing Physical Assessment

• List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)

Related Treatments

• Explain what treatments  the patient is receiving because of his/her disease

Nursing Diagnosis & Patient Goal

• Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
• Explain what your goal is for helping the patient recover (What do you want to change for the patient?)

 Nursing Interventions

• Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)

 Evaluation

• Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)

 Recommendations

• Explain what the patient or nurse should do in the future to continue recovery/improvement

Background and Physical Examination

J. P.  is a 46-year-old man presents to the emergency department with a 5-day history of progressively worsening breathlessness on exertion and mild, general flulike symptoms. He also complains about night sweats and an intermittent low-grade fever, both of which started about 2 weeks ago.

Upon physical examination, the patient does not appear to be in any acute distress. His vital signs are measured as a pulse of 89 beats/min, blood pressure of 140/85 mm Hg, and a respiratory rate of 19 breaths/min. He is afebrile, with a temperature of 99.8°F (37.7°C).

The chest examination reveals nothing out of the ordinary, and his cardiovascular and respiratory examinations, including auscultation, are unremarkable. The abdominal examination reveals no fluid thrill, shifting dullness, or bruit. The liver and the spleen are not enlarged. No lymph nodes are palpable.

Multiple areas of hyperpigmentation are noted; otherwise, the skin inspection is unremarkable, with no hematomas, bruises, wounds, or scars noted. Electrocardiography (ECG) reveals a sinus rhythm with a heart rate of 84 beats/min, and the T waves are somewhat flattened in leads V1, aVL, and III, but they are otherwise unremarkable.

Laboratory Test Results and Other Findings

Significant laboratory findings include a white blood cell count of 9.1 x 103/µL (9.1 x 109/L; reference range, 3.5-8.8 x 109/L), a platelet count of 429 x 103/μL (429 x 109/L; reference range, 140-350 109/L), a C-reactive protein level of 91 mg/L (reference range, < 10 mg/L), a lactate dehydrogenase (LDH) level of 4.7 microkatals (µkat)/L (reference range, < 3.5 µkat/L), an erythrocyte sedimentation rate (ESR) of 30 mm (reference range, 1-12 mm), and a D-dimer of 2.2 mg/L (reference range, < 0.25 mg/L).

A spiral CT scan is performed, which shows no pulmonary embolism. It does, however, reveal the presence of a significant pericardial effusion (1 cm ventral x 2.5 cm dorsal) and a multilobular substernal mass occupying the anterior superior mediastinum that is about 2.5 cm in thickness and 7 cm in length, with high absorption. Additionally, the mediastinal lymph nodes are enlarged; some are as large as 2 cm in size. No other pertinent findings on spiral CT are reported.

An emergent bedside echocardiogram is obtained. The echocardiographic findings confirm the presence of pericardial effusion, without signs or symptoms of a cardiac tamponade; additionally, a retrosternal mass is detected

Which of the following is the most likely diagnosis?

B. Thymoma

Your paper should be 3-4 pages in length and will be graded on how well you complete each of the above sections. You will also be graded on your use of APA style and on your application of nursing journals into the treatments and interventions. For integrating nursing journals, remember the following: 

• Make sure to integrate citations into all of your paper
• Support all claims of what the disease is, why it occurs and how to treat it with references to the literature on this disease
• Always use citations for information that you learned from a book or article; if you do not cite it, you are telling your reader that YOU discovered that information (how to treat the disease, etc.)

Review the rubric for specific grading criteria. 

Points possible: 60