Week 6: Discussion Part One
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”|
|Characteristics||Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well well rested. “No energy to do anything I normally can do”|
|Relieving factors||None identified|
|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 of 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|
|Medications||Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU.|
|PMH||HTN, Depression, Postmenopausal status|
|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 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
|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|
|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.