NR511 Week 6 discussion part one and Two

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Week 6: Discussion Part One

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Date of visit: November 7, 2017

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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

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

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;

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.

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
  • 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.

Week 6: Discussion Part Two

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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