Week 6: Clinical Case Study Part One Discussion
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Purpose
Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving actual patient problems in the same manner as they occur in practice. The purpose of this activity is to develop students’ clinical reasoning skills using a case-based learning exercise. Through participation in an online discussion forum, students identify learning issues in a self-directed manner which facilitates learning for the entire group.
Activity Learning Outcomes
Through this discussion, the student will demonstrate the ability to:
- Synthesize clinical knowledge, didactic learning and research findings to provide appropriate primary care to patients with common acute and stable chronic conditions. (WO6.1) (CO 1, 2, 4 & 5)
Due Date:
Student enters initial post to part one by 11:59 p.m. MT on TUESDAY; responds substantively to at least one topic-related post of a peer including evidence from appropriate sources AND all direct faculty questions in parts one by Sunday, 11:59 p.m. MT.
A 10% late penalty will be imposed for discussions posted after the deadline on TUESDAY 11:59pm MT, regardless of the number of days late. NOTHING will be accepted after 11:59pm MT on Sunday (i.e. student will receive an automatic 0). Week 8 discussion closes on Saturday at 11:59pm MT.
Total Points Possible: 50
Requirements:
- 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.
- 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.
Case Study
Date of visit: November 7, 2017
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 |
Solution:
Week 6 case presentation part 1
Summary of H&P findings
A Caucasian female aged 56 presents to the clinic with a CC of fatigue. She reports that she has been feeling generally tired throughout for the last 2 to 3 months, which has continued to worsen. She does not feel well-rested despite normally sleeping for 8 hours every night. She reports the inability to function normally which has resulted in her missing a workday 2 weeks ago as she could not get out of bed. The feeling of lack of energy is constant and the fatigue worsens on exertion. The patient denies any taking any medication for symptom relief. She denies any pain. The patient has a PMH of depression, HTN, Tonsillectomy, and Postmenopausal. Her current medications include Multivitamin, B-Complex, Prozac 20mg Bisoprolol-HCTZ 2.5mg/6.25mg, and Calcium 500mg with 400IU of Vit D3…..Please click the icon below to purchase the full solution at $10