Writing Homework Help

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.

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.

1. 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.
2. Case Study
3. Date of visit: November 7, 2017
4. 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.
5. 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

**To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric.

DISCUSSION CONTENT 

Category 

Points 

% 

Description 

Application of Course Knowledge 

15 

30% 

A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND

Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND

A brief statement of pathophysiology is included for each diagnosis; AND

Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND

The differential is ranked in order from most likely to least likely; AND

Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND

Testing decisions are well supported with EBM arguments that are in-line with the clinical scenario and appropriate for the primary care setting 

(7 critical elements) 

Support from Evidence-Based Practice (EBP) 

15 

30% 

Discussion post is supported with appropriate, scholarly sources; AND  

Sources are published within the last 5 years (unless it is the most current CPG); AND 

Reference list is provided and in-text citations match; AND 

All testing decisions are fully supported with an appropriate EBM argument 

(4 critical elements) 

Interactive Dialogue 

10 

20% 

Student provides a substantive* response to at least one topic-related post of a peer; AND 

Evidence from appropriate scholarly sources are included; AND 

Reference list is provided and in-text citations match; AND 

Student responds to all direct faculty questions 

(*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response 

(4 critical elements) 

Total CONTENT Points= 40 pts 

DISCUSSION FORMAT 

Category 

Points 

% 

Description 

Organization 

5 

10% 

Case study response is presented in a logical format, AND 

Responses are in sequence with the numbered questions AND 

The case study response is understandable and easy to follow AND 

All responses are relevant to the case topic 

(4 critical elements) 

Grammar, Syntax, Spelling & Punctuation 

5 

10% 

Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors* 

Total FORMAT Points= 10 pts 

DISCUSSION TOTAL= 50 pts

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

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)

**To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric.

DISCUSSION CONTENT 

Category 

Points 

% 

Description 

Application of Course Knowledge 

15 

30% 

Student chooses one appropriate diagnosis for the patient; AND 

Diagnosis is supported with strong pertinent positive and negative subjective and objective data from parts 1 & 2; AND 

The ICD code for the diagnosis is correct; AND 

Treatment plan for primary diagnosis includes medication, additional testing, patient education, and referral; AND 

Prescription and OTC medications are written appropriately as a RX and all components are correct; AND  

Treatment decisions (medication, additional testing, referrals) are supported with appropriate EBM arguments; AND  

An accurate problem list is presented based on case information; AND  

Student discusses changes (or not) to the overall treatment plan for the patient for pertinent issues; AND  

An appropriate F/U plan is provided 

(9 critical elements) 

Support from Evidence-Based Practice (EBP) 

15 

30% 

Discussion post is supported with appropriate, scholarly sources AND 

Sources are published within the last 5 years (unless the most current CPG is used) AND 

A reference list is provided with in-text citations that match AND 

All treatment and testing decisions are fully supported with an appropriate EBM argument 

(4 critical elements) 

Interactive Dialogue 

10 

20% 

Student provides a substantive* response to at least one topic-related post of a peer AND 

Includes evidence from appropriate scholarly sources AND 

Provides a reference list which match in-text citations AND 

Student responds to all direct faculty questions 

(4 critical elements) 

Total CONTENT Points= 40 pts 

DISCUSSION FORMAT 

Category 

Points 

% 

Description 

Organization 

5 

10%