Clinical Case Study Paper

Clinical Case Study Paper

Week 6: Clinical Case Study Part One Discussion

Requirements:

 

  1. 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.
  2. 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
  1. 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.
  1. Rank the differential in order of most likely to least likely.
  2. 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

  1. 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

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Week 6: Clinical Case Study Part Two Discussion

Requirements:

  1. 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)
  2. Identify the corresponding ICD-10 code.
  3. 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
  4. Provide an active problem list for this patient based on the information given in the case.
  5. 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.
  6. 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