Diagnosis Assignment Paper
Diagnosis Assignment Paper
The purpose of the Aquifer assignment is to teach you how to synthesize important patient information gathered during an office visit to select appropriate differentials and create subsequent diagnostic and treatment plans.
The Aquifer assignment is not a summarization of the Aquifer case, or an essay on the specific illness/disease presented.
The written portion of the Aquifer assignment should clearly outline your rationale for selecting your leading diagnosis and differentials, given the information collected for the patient presented.
While the write up needs to include an appropriately formatted title page per APA 7 guidelines, a formal introduction and conclusion are not needed. Diagnosis Assignment Paper
An example outline of the written assignment should include would be as follows:
Leading Diagnosis
(this is the diagnosis for which diagnostic and treatment plan will be written)
The leading diagnosis for this patient is ****. Leading diagnosis is supported by patient’s presenting symptoms of ***** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). Supporting physical assessment findings include ****** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Differential Diagnoses (must have 2 differentials)
Differential 1 (e.g. Influeza)
The first differential in this case is **** supported by patient presentation of *** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). The differential is further supported by physical exam findings of **** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). *** is less likely however due *(here you would present s/s, history physical exam findings that rule out differential)* (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Differential 2 (e.g. Viral pharyngitis)
*** is the second possible differential in this case. Differential is supported by patient’s presenting symptoms of **** (citation). Patient’s physical assessment findings of *** further support the differential however, differential is less likely due to *** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Diagnostics
Here you would outline your diagnostic plan including any pertinent diagnostic test(s) or exam(s) indicated for diagnosis (must include citation of a Clinical Practice Guideline unless not available. If no guideline is available may use a Problem Specific Peer Reviewed Reference). Brief statement regarding why test is being used, e.g. Positive RADT results are confirmatory for GAS in pediatric patients (Clinical Practice Guideline or Problem Specific Peer Reviewed Reference citation).
Treatment Plan
*** is the first line treatment for *** (must include citation of a Clinical Practice Guideline unless not available. If no guideline is available may use a Problem Specific Peer Reviewed Reference) Any medications should include name, route, dose, and duration (Clinical Practice Guideline or Problem Specific Peer Reviewed Reference citation). Supportive measures recommended, including ***** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). Follow up **** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings) Diagnosis Assignment Paper
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References (documented per APA 7 guidelines)
Must include an appropriate clinical practice guideline unless there is not a written guideline for diagnosis. In the case no guideline is available a peer reviewed article written on the specific diagnosis selected may be used.
Aquifer Case Study #18 Family Medicine: Migraine Headaches without Aura
Leading diagnosis
The leading diagnosis for S.P. is migraine headaches without aura. A diagnosis of migraine headaches without aura is supported by the patient’s report of unilateral and severe throbbing pain associated with nausea, photophobia, and hyperacusis occurring 2-3 times weekly (Cutrer, 2022). S.P meets 5 of the ICHD-3 diagnostic criteria for migraine without aura, including 1) having 5 attacks 2) headache attacks that last 4-72 hours, 3) characteristics such as unilateral pulsating headache, 4) nausea, vomiting, and photophobia during headache, and 5) does not match other ICHD-3 diagnosis (Cutrer, 2022).
Differential Diagnoses
Differential diagnoses for this patient include cluster-type headaches and anxiety.
Cluster-Type Headaches
The first differential for S.P. is cluster-type headaches, supported by a debilitating unilateral and severe throbbing pain that’s associated with nausea, photophobia, and hyperacusis that occurs 2-3 times a week and results in the patient having to go home. However, this is ruled out due to lack of autonomic symptoms such as ptosis, miosis, lacrimation, conjunctival injection, sweating, and/or nasal congestion (May, 2022).
Anxiety
Another differential is headache due to anxiety supported by S.P. ‘s report of a stressful lifestyle with schooling, part time work, and recent breakup with a boyfriend who cheated. (Taylor, 2020). However, this is ruled out as the patient’s GAD-2 score was 2, testing negative (Taylor, 2020).
Diagnostics
Diagnostic testing of MRI for migraine isn’t needed in this patient given her age of under 50 or having cognitive changes (Ng & Hanna, 2021). The patient would not need other laboratory tests given the negative physical examination (Cutrer, 2022).
Treatment Plan
S.P. ‘s migraine can be treated with oral sumatriptan 100 mg PO as needed for headaches and can be repeated in 2 hours, but do not exceed over 200 mg in a 24-hour period (Ng & Hanna, 2021). The patient can also take a combo therapy of acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg orally PRN for tension-type headaches (Taylor, 2020). The patient should reduce her caffeine intake from other sources if it’s a trigger for her headaches.
S.P. should have a follow up appointment in 2 weeks to see if the medication worked. The patient in the meantime should keep a journal of headache triggers and patterns and reduce stressors in her life that could contribute to the tension-type headaches. She can also exercise four times a week, use relaxation therapies, and improve sleep (Schwedt & Garza, 2022). Diagnosis Assignment Paper
References
Cutrer, M. (2020). Pathophysiology, clinical manifestations, and diagnosis of migraine in adults. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-migraine-in-adults?search=migraine&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
May, A. (2022). Cluster headache: Epidemiology, clinical features, and diagnosis. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/cluster-headache-epidemiology-clinical-features-and-diagnosis?search=cluster%20headache&source=search_result&selectedTitle=1~47&usage_type=default&display_rank=1#H6
Ng, J. Y., & Hanna, C. (2021). Headache and migraine clinical practice guidelines: A systematic review and assessment of Complementary and Alternative Medicine Recommendations. BMC Complementary Medicine and Therapies, 21(1). https://doi.org/10.1186/s12906-021-03401-3
Schwedt, T. & Garza, I. (2020). Acute treatment of migraine in adults. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults?search=migraine%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7
Taylor, F. (2020). Tension-type headache in adults: Acute treatment. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/tension-type-headache-in-adults-acute-treatment?search=tension%20headache&topicRef=3357&source=see_link#H8
Case Analysis Tool Worksheet
Student’s Name: Iris Molina Case ID: Molina_AQ_22
- Epidemiology/Patient Profile
| Mr. Wright is a 70-year-old male who came to the clinic for checkup after an incident of fall. He states that he felt dizziness, numbness and tingling in his left arm and hand. He is a widower that lives alone and has two daughters and a son that lives nearby. Denies headaches, change in speech or vision, chest pain. |
- Prioritized Cues from History and PE.
Tier 1 Tier 2 Tier 3
| Numbness and tingling in left arm and hand | No incontinence of urine or stool | Some right knee soreness |
| Visual Disturbances | Slower response to time to questions | Peptic ulcer disease |
| Dizziness and lightheadedness but no loss of consciousness | PMI (PMI) 5th intercostal space but laterally displaced 3cm | Cataract |
| Blood pressure: 166/82 mmHg | Family History: Type 2 diabetes mellitus, hypertension, glaucoma | BPH |
| Left arm weakness | Alcohol consumption | Widowed |
| History of Essential hypertension (poorly controlled) Diagnosis Assignment Paper | Sons lives nearby | |
| Hyperlipidemia (poorly controlled) | ||
| Muscle weakness (2/5) | ||
| Tachycardia (168 bpm) with irregularly irregular rhythm | ||
| Smoking – 1/2 pack per day resumed four years ago after 10-year abstinence | ||
| Symptoms resolved after 15 minutes | ||
| No current neurological deficits on examination | ||
| Age: 70 years | ||
| Atrial fibrillation with Irregularly irregular heart rate of 168 beats/minute | ||
| LDL 129 mg/dl | ||
| (-) JVD bruits |
| Mr. Wright, a 70-year-old man with uncontrolled hypertension and hyperlipidemia, arrives to the clinic after falling due to an episode of lightheadedness. The associated left hand numbness and vision disturbance subsided after 15 minutes, but there was no loss of consciousness. The physical exam is notable for tachycardia, irregularly irregular heart rhythm, and increased blood pressure. |
III. Problem Statement
- Differential Diagnosis
Leading dx: Transient Ischemic Attack
History Finding(s) Physical Exam Finding(s)
| Dizziness and lightheadedness but no loss of consciousness | Blood pressure: 166/82 mmHg |
| Numbness and tingling in left arm and hand | No current neurological deficits on exam |
| Visual disturbances | LDL 129 mg/dl |
| Symptoms resolved after 15mins | Tachycardia |
| History of essential hypertension (poorly controlled) | Atrial Fibrillation with irregularly irregular heart rate of 168 beats/minute |
| Smoking | |
| Age: 70 years |
Alternative dx: Stroke
History Finding(s) Physical Exam Finding(s)
| Dizziness and lightheadedness but no loss of consciousness | Blood pressure: 166/82 mmHg |
| Numbness and tingling in left arm and hand | LDL 129 mg/dl |
| Visual disturbances | Tachycardia |
| Smoking | Atrial Fibrillation with irregularly irregular heart rate of 168 beats/minute |
| Race: African American (more likely to have stroke) (Cash, et. al., 2021) | Slower response to time to questions |
Alternative dx: Atrial Fibrillation
History Finding(s) Physical Exam Finding(s)
| Dizziness and lightheadedness | EKG finding: Atrial Fibrillation with LVH, inferior and lateral ST depression |
| Visual disturbances | Irregularly Irregular rate of 168 beats/min |
| Hypertension | Tachycardia: HR: 118 |
- Explanation of Diagnostic Plan and Treatment Plan in prioritized order:
Diagnostic Plan Rationale
| EKG | Evaluation of dysrhythmia (Cash, et al., 2021) |
| Brain imaging with head CT and/or MRI | For individuals with TIA, brain MRI using diffusion-weighted imaging is more sensitive than CT at finding small infarcts. Additional data from multimodal CT and MRI tests may help in ischemic stroke diagnosis. |
| CBC and PT/PTT | Infectious, hypoxic/hypoperfusion, thrombotic, and hemorrhagic etiologies should be taken into consideration when the CBC and PT/PTT are abnormal. To obtain baseline before starting antithrombotic drug. |
| Cardiac Markers | Since myocardial ischemia is a potential side effect of acute cerebrovascular illness, markers for cardiac ischemia are crucial for all patients with suspected ischemic stroke. |
| Glucose check | Rule out hypoglycemia |
| B-type Natriuretic Peptide (BNP) | An increased level can indicate acute stroke. |
| Oxygen Saturation | The cause of a stroke may be underlying CAD, and by maintaining normal oxygen saturation, the severity of brain damage may be reduced. Stroke patients who are hypoxic need supplemental oxygen. |
Treatment Plan Rationale
| Rapid transfer to hospital | Emergent situation, higher acuity of care (MRI) |
| Antiplatelet Therapy once bleeding is ruled out | It lowers the likelihood of clot formation (Fox, 2019). Aspirin is the preferred platelet inhibitor. For patients who can’t take aspirin, most providers reserve clopidogrel and utilize it as a last resort. Based on patient preference, the predicted risk of bleeding if anticoagulation is used, and access to high-quality anticoagulation monitoring, it is advised for low-risk and certain moderate-risk patients with AF. The suggested dose is 81 mg because greater doses, such 325 mg, increase adverse effects without significantly lowering the risk of stroke. |
| Antihypertensive
Blood pressure lowering to a goal of 130/80 mmHg using antihypertensive (Thiazide-like Diuretic: Hydrochlorothiazide + Amlodipine + Metoprolol 25 mg PO daily) |
In people who have had an ischemic stroke and are past the hyperacute stage, antihypertensive therapy is advised for the prevention of recurrent stroke and other vascular problems. Based on its extended half-life and demonstrated decrease of CVD in clinical trials, hydrochlorothiazide is chosen. Keep an eye on uric acid and calcium levels, as well as hyponatremia and hypokalemia. Metoprolol and Amlodipine are introduced for better control (the patient has already been taking them) (to control his heart rate as well). |
| Lipid control (High intensity Statin therapy: Atorvastatin 40 mg daily) | All patients with a history of TIA or CVA should be placed on high-intensity statin such as atorvastatin 40 or 80 mg or rosuvastatin 20 mg |
| Educate on medication adherence | Management of associated risk factors |
| Reduce alcohol consumption | Decrease or eliminate risk factors (Cash., et. al., 2021) |
| Smoking Cessation | Smokers who have had an ischemic stroke or transient ischemic attack should be strongly advised not to smoke. |
| Stroke Education | Stroke education including knowledge of stroke warning signs and need to call 911 in the event of a cerebrovascular event as well as awareness of individual’s own risk factors. |
| Diet | All people are advised to follow a Mediterranean diet by the ACC/AHA Lifestyle Guidelines in order to lower their risk of ASCVD. Additionally, people with hypertension need to keep their daily sodium consumption to 2,400 mg or fewer. |
| Exercise plan to reduce weight | All adults are urged to engage in physical exercise of moderate to vigorous intensity three to four times per week for a total of forty minutes, based on moderate quality evidence. It is advised to follow a supervised rehabilitative exercise program for people who have disabilities following an ischemic stroke. |
I have adhered to the honor system: Yes
Student’s signature
References
Cash, J. C., & Glass, C. A. (2017). Family Practice Guidelines (4th ed.). Springer Publishing.
Fox, C., (2019). Ischemic stroke in children: Clinical presentation, evaluation, and diagnosis. UpToDate.
Retrieved from https://www.uptodate.com/contents/ischemic-stroke-in-children-clinical-presentation
evaluation-and-diagnosis
IRIS
