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A 30 year old with multiple life stressors presents with 2 days of achy, 7/10 non radiating pain following an argument with her partner in which he applied force to her throat with one hand for approximately 30 seconds. She reports escalating arguments with spouse leading up to the recent incident which included breakage of her personal objects and financial constraints, followed by feelings of sleeplessness, edginess, and nightmares. She continues to work as a dental Hygienist but reports tenderness and difficulty with neck flexion, unrelieved by supportive care. She denies loss of consciousness or current hoarseness, dysphagia, dyspnea, or sexual abuse. Physical exam shows stable vital signs, handprint shaped ecchymoses on anterior neck, and ecchymoses in various stages of healing on limbs without truncal injury, lacerations, or bleeding. Vital signs Temp 37.3C (99.1F) oral, Pulse 86, Blood pressure left 114/78, 114/78 right, normal visual acuity, Skin is intact, Head is normocephalic, no swelling. Neck has full ROM, no tracheal deviation. NO heart murmurs, breath sounds are clear.

 

Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

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Step-by-Step Guide to Writing Your Clinical Case Report

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Step 1: Understand the Case and Requirements

1. Review the details of the patient’s presentation thoroughly, including:
   • Chief complaint (neck pain and tenderness following an altercation).
   • Relevant history (domestic abuse, escalating conflicts, financial constraints).
   • Physical findings (ecchymoses, no loss of consciousness, normal exam except for bruising and tenderness).
2. Identify the key elements of the case, such as:
   • Trauma to the neck (potential airway or vascular injury).
   • Psychosocial stressors and history of intimate partner violence (IPV).
3. Ensure you understand the structure of your case report, which may include sections like history, physical exam findings, differential diagnosis, evaluation, management plan, and recommendations.

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Step 2: Organize the Structure of Your Report

Your report should follow this format:

1. Introduction:
   • Provide a brief overview of the case.
   • Highlight the significance of IPV in healthcare and its implications on physical and mental health.
2. Patient Presentation:
   • Describe the patient’s demographics, complaints, and relevant medical/social history.
3. History of Present Illness (HPI):
   • Detail the events leading to the current complaint, focusing on the physical and emotional trauma.
4. Physical Examination Findings:
   • Document all relevant findings (e.g., handprint-shaped ecchymoses on the neck, various ecchymoses on limbs, no airway compromise).
5. Differential Diagnosis:
   • Include possible diagnoses such as:
     • Neck strain or soft tissue injury.
     • Laryngeal trauma.
     • Psychological sequelae of IPV (PTSD, anxiety).
6. Assessment and Plan:
   • Summarize the clinical findings.
   • Propose a management plan, addressing both physical injuries and psychosocial concerns.
7. Discussion:
   • Provide an analysis of IPV’s impact on health.
   • Discuss the importance of early identification and intervention.
8. Conclusion:
   • Highlight key takeaways and recommendations for care and follow-up.

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Step 3: Conduct Research

• Use trusted sources such as medical journals, clinical guidelines, or textbooks to gather evidence on:
  • IPV screening tools.
  • Management of neck trauma.
  • Psychological support for IPV survivors.

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Step 4: Draft Each Section

• Write concisely and clearly, ensuring each section flows logically.
• Incorporate evidence-based practices for trauma assessment and IPV management.
• Include quotes or paraphrased material with proper citations to support your statements.

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Step 5: Address Key Considerations

• Safety Planning: Discuss the need for resources like social services, shelters, and counseling for IPV victims.
• Documentation: Emphasize clear and objective documentation of physical findings for legal and medical purposes.
• Mandatory Reporting: Review local guidelines for IPV reporting requirements.

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Step 6: Revise and Proofread

• Check for grammatical errors and medical accuracy.
• Ensure sensitive language is used when discussing IPV to avoid re-traumatization.
• Confirm all cited references are accurate and properly formatted.

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Step 7: Submit Your Report

• Review the final draft to ensure clarity and completeness.
• Ensure the report adheres to formatting guidelines provided by your instructor or organization.

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By following this structured approach, you will create a thorough, empathetic, and clinically sound case report that addresses the patient’s physical and emotional well-being. Good luck!

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