Csusap.csu.edu.au

CASE STUDY 3
Background
Jane Stevens, a 72-year-old Caucasian woman, presents to her GP complaining of upper back pain. She reports the pain has been slowly progressive over the past few years. However, recently she sneezed and the pain immediately intensified and was more sharp and localised. She thinks she may have pulled a muscle. A review of the patient's previous medical records revealed that Jane had a complete hysterectomy at age 45. She has never received hormone therapy. She has a history of low trauma fractures to her left wrist. She also has chronic rheumatoid arthritis and chronic obstructive pulmonary disease. Jane’s GP schedules anterior-posterior and lateral thoracic spine x-rays, which provide evidence of a recent fracture in T3. The radiologist also notes low bone density throughout the spine. Questions
1. Given all the information provided in this case study, what chronic health condition mostly likely explains Jane’s most recent vertebral fracture? Explain your position. (100 words) 2. What clinical assessment/s could be performed to confirm the presence of the condition you identified in question 1? In your response make sure to include necessary diagnostic criteria. (100 words) 3. In addition to the details provided in this case study, what other factors may have contributed to the development of Jane’s most recent chronic health condition? (~100 words). 4. Describe possible treatments to assist Jane her reduce risk of future fracture. (200-400 5. Discuss the relationship between the Jane’s medical history and prior chronic health conditions and the development of her most recent health condition. (750 words) NOTE: Only the health summary sheet of the GPMP/TCA is provided for this case.
Dr Bill Jones
Good Health Medical Practice
CHRONIC DISEASE MANAGEMENT
GP Management Plan (721) and/or Team Care Arrangement (723)
PATIENT DETAILS:
DETAILS OF PATIENT’S
DETAILS OF PATIENT’S USUAL
CARER (IF APPLICABLE):
Phone: (02) 6497 2254
DOB: 30/04/1938
Phone: (02) 1234 5678
Medicare Number: 2717 3164 3 / w

Date of Last GP Management Plan / Team Care Arrangements (if done): None recorded.
Other notes or comments relevant to the GP Management Plan / Team Care Arrangements: None recorded.
MEDICAL HISTORY:
FAMILY/SOCIAL HISTORY /
LIFESTYLE HISTORY:
Condition
SUPPORTS:
Smoking:
Alcohol:
Exercise:
CURRENT MEDICATIONS:
Medications
Strength
Dose / Frequency
Assessed: 3/05/2010
Age: 72 years
Height: 163cm
Weight: 54 kg
BMI: 20 kg.m-2
BP: 135/78 mmHg
Pulse: 78 bpm
BLOOD CHEMISTRY:
Assessed: 5/04/2009
Total Cholesterol: 4.3 mmol/L LDL-C: 2.5 mmol/L
HDL-C: 1.0 mmol/L
Triglycerides: 2.7 mmol/L
Fasting BGL: 5.2 mmol/L
OTHER INFORMATION:
Allergies:
Immunisations:

Copy of Team Care Arrangements offered to patient?
Team Care Arrangements added to the patient’s records?
Copy / relevant parts of the Team Care Arrangements supplied to other providers?
Referral forms for Medicare allied health and dental care services completed?

Date TCA was completed: 10/05/2010
Proposed TCA Review Date: 18/10/2010

Source: http://csusap.csu.edu.au/~sbird/EHR503/Assessment/CS3_GPMP.pdf