Clinical Case Study

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.
3. Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
4. Rank the differential in order of most likely to least likely.
5. 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