Week 6: Clinical Case Study Part One Discussion
Requirements:
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Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information.
Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement of pathophysiology for each. Clinical Case Study
Analyze the differential by comparing and contrasting the possibilities. Use pertinent positive and negative findings to argue for or against each diagnosis in your differential. Rank your diagnoses in order of most likely to least likely with EBM references.
Rank the differential in order of most likely to least likely.
Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBM evidence.
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Case Study
A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Upon further questioning you discover the following subjective information regarding the chief complaint.
History of Present Illness
Onset
“about 2-3 months”
Location
Generalized
Duration
Constant
Characteristics
Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well rested. “No energy to do anything I normally can do”
Aggravating factors
Exertion . Clinical Case Study
Relieving factors
None identified
Treatments
None
Severity
Denies pain; missed 1 day of work 2 weeks ago because “couldn’t get out of bed”
Review of Systems (ROS)
Constitutional
Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months ago.
Eyes
No visual changes or diploplia
ENT
Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea.
Neck
Denies lymph node tenderness or swelling
Chest
Denies cough, SOB, DOE or wheezing
Heart
Denies chest pain
Abdomen
Denies N/V/D. + Constipation
Endocrine
Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.
Skin
No changes in skin, hair or nails
Psych
Reports worsening of depressive symptoms but thinks it is because she is so “unproductive” lately and tired all of the time. -Suicidal or homicidal thoughts. Sleeping 8-9hrs per night (no changes), but not feeling rested.
Musculoskeletal
Generalized weakness and intermittent muscles cramping in calves
Clinical Case Study
History
Medications
Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU.
PMH
HTN, Depression, Postmenopausal status
PSH
Tonsillectomy
Allergies
Iodine dyes
Social
Married; Works full time as office manager of an internal medicine office; 2 kids (grown)
Habits
Denies cigarettes or drug use. +Occasional glass of wine (1-2 per month).
FH
Maternal GM & GF deceased with CHF, T2DM and HTN;Mother alive (age 82) +HTN, +Hyperlipidemia, +T2DM; Clinical Case Study
Father alive (age 84) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p CABG 2 years ago). Also had +CVA at time of CABG (work-up revealed +DVT and +PFO; remains anticoagulated);
Oldest child (26) with seasonal allergies
Youngest child (24) with Bipolar depression and ADHD, and anxiety
Physical exam reveals the following:
Physical Exam
Constitutional
Middle aged Caucasian female alert, oriented and cooperative
VS
Temp-98.2, P-74, R-16, BP 146/95, Height: 5’7″, Weight: 180 pounds
Head
Normocephalic, atraumatic
Eyes
PERRLA
Ears
Tympanic membranes gray and intact with light reflex noted.
Nose
Nares patent. Nasal turbinates without swelling. Nasal drainage is clear.
Throat
Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities.
Neck
Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Clinical Case Study.
Cardiopulmonary
Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. No pedal edema
Abdomen
Soft, non-tender. BS active
Skin
Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Psych
Mood pleasant and appropriate.
Musculoskeletal
Strength full throughout
Neuro
DTRs 2+ at biceps, 1+ at knees and ankles
Week 6: Clinical Case Study Part One Discussion
Week 6: Clinical Case Study Part Two Discussion
Requirements:
What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)
Identify the corresponding ICD-10 code.
Provide a treatment plan for this patient’s primary diagnosis which includes:
Medication*
Any additional testing necessary for this particular diagnosis*
Patient education
Referral. Clinical Case Study
Provide an active problem list for this patient based on the information given in the case.
Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBM argument for each treatment or testing decision.
Provide an appropriate F/U plan.
*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an evidence-based medicine (EBM) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.
Case Study
Now, assume that you sent your patient for labs and she returns the following day, as instructed, to review the results.
CBC with differential
WBC
8.6 x10E3/uL
RBC
4.44 x 10E6/uL
Hemoglobin
14.0 g/dL
Hematocrit
41.2%
MCV
93fL
MCH
31.5 pg
MCHC
34.0 g/dL
RDW
13%
Platelet
241 x 10E3/uL
Neutrophils %
67%
Lymphocytes %
22%
Monocytes %
8%
Eosinophils %
3%
Basophils %
0%
Absolute Neutrophils
5.7 x 10E3/uL
Absolute Lymphocytes
1.9 x 10E3/uL
Absolute Monocytes
0.7 x 10E3/uL
Eosinophils Absolute
0.3 x 10E3/uL
Basophile Absolute
0.0 x 10E3/uL
Immature Grans %
0%
Absolute Immature Grans
0.0 x 10E3/uL
TSH with Reflex to FT4
TSH
6.770 uIU/mL
FT4
0.62 ng/dL
PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago) Clinical Case Study
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