NR511 week 6 discussion (dq1+dq2) latest 2018 march
Week 6
discussion
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DQ1
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 |
|
Aggravating factors |
Exertion |
|
Relieving factors |
None identified |
|
Treatments |
None |
|
Severity |
Denies pain; missed 1 day of work 2 weeks |
|
Review of Systems (ROS) |
|
|
Constitutional |
Denies fever, chills, or recent illnesses. |
|
Eyes |
No visual changes or diploplia |
|
ENT |
Denies ear pain, coryza, rhinorrhea, or ST. |
|
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 |
|
Skin |
No changes in skin, hair or nails |
|
Psych |
Reports worsening of depressive symptoms but |
|
Musculoskeletal |
Generalized weakness and intermittent |
|
History |
|
|
Medications |
Multivitamin, B-Complex, Prozac 20mg, |
|
PMH |
HTN, Depression, Postmenopausal status |
|
PSH |
Tonsillectomy |
|
Allergies |
Iodine dyes |
|
Social |
Married; Works full time as office manager |
|
Habits |
Denies cigarettes or drug use. +Occasional |
|
FH |
Maternal GM & GF deceased with CHF, T2DM and HTN; Mother alive (age 82) +HTN, +Hyperlipidemia, +T2DM; Father alive (age 84) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p Oldest child (26) with seasonal allergies Youngest child (24) with Bipolar depression |
Physical exam reveals the following:
|
Physical Exam |
|
|
Constitutional |
Middle aged Caucasian female alert, oriented |
|
VS |
Temp-98.2, P-74, R-16, BP 146/95, Height: |
|
Head |
Normocephalic, atraumatic |
|
Eyes |
PERRLA |
|
Ears |
Tympanic membranes gray and intact with |
|
Nose |
Nares patent. Nasal turbinates without |
|
Throat |
Oropharynx moist, no lesions or exudate. |
|
Neck |
Neck supple. No lymphadenopathy. Thyroid |
|
Cardiopulmonary |
Heart S1 and s2 noted, no murmurs, noted. |
|
Abdomen |
Soft, non-tender. BS active |
|
Skin |
Skin overall dry, hair coarse and thick, |
|
Psych |
Mood pleasant and appropriate. |
|
Musculoskeletal |
Strength full throughout |
|
Neuro |
DTRs 2+ at biceps, 1+ at knees and ankles |
Briefly and concisely summarize the 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.
Analyze the differential by using the pertinent findings
from the history and physical to argue for or against a diagnosis. 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.
DQ2
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)
What is your primary diagnosis for this patient as the cause
for the CC of fatigue? (support your 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 and follow-up to the treatment plan
Provide an active problem list for this patient based on the
information given in the case.
Are there any changes that you would make to the patient’s
overall plan at this time? Must provide an evidence-based medicine (EBM)
argument to support any treatments or testing decisions.
Provide an appropriate follow-up plan (include any
additional testing that you feel is necessary and include an EBM argument).
*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 EBM argument.
Over-the-counter (OTC) and RXs must be written in full as if handing a script
to the patient in the office.
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