NR511 Week 3 Discussion (dq1+dq2) Latest 2020 MAY

NR511 Differential Diagnosis and Primary Care

Week 3 Discussion

DQ1 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. (WO3.2) (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: October 20, 2017

A 19-year-old male freshman college student presents to the student health center today with complaints of bilateral eye discomfort. Upon further questioning you discover the following subjective information regarding the chief complaint.

History of Present Illness
Onset	2-3 days ago
Location	Both eyes
Duration	Constant
Characteristics	Both eyes feel “gritty” with mild to moderate amount of discomfort. Further describes the gritty sensation “like sand caught in your eye”
Aggravating factors	None identified
Relieving factors	None identified
Treatments	Tried OTC visine drops once yesterday which temporarily improved the redness but the gritty sensation, tearing and itching remained.
Severity	Level of discomfort is 2/10 on pain scale

 

Review of Systems (ROS)
Constitutional	Denies fever, chills, or recent illnesses
Eyes	Denies contact lenses or glasses, has never experienced these symptoms previously. Last eye exam was “a few years ago”. Denies eye injury, trauma, visual changes or dryness. Denies crusting of lids or mucoid or purulent drainage. Bilateral symptoms of +redness, +itching, +tearing + FB sensation.
Ears	-otalgia, -otorrhea
Nose	+occasional runny nose with intermittent nasal congestion, denies sneezing. History of seasonal nasal allergies which is aggravated in the spring but is well controlled on loratadine and fluticasone nasal spray taken during peak season (he is not taking either right now).
Throat	Denies ST and redness
Neck	Denies lymph node tenderness or swelling
Chest	Denies cough, SOB and wheezing
Heart	Denies chest pain

 

History
Medications	Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring months when nasal allergies flare)
PMH	Seasonal allergic rhinitis with springtime triggers
PSH	None
Allergies	None
Social	Freshman student at the University of Awesome located in central Illinois. Home is in Phoenix.
Habits	Denies cigarettes +recreational marijuana use +drinks 3-6 beers per weekend
FH	Adopted, does not know biological parents history

Physical exam reveals the following.

Physical Exam
Constitutional	Young adult male in NAD, alert and oriented, cooperative
VS	Temp-97.9, P-68, R-16, BP 120/75, Height 6’0, Weight 195 pounds
Head	Normocephalic
Eyes	Visual Acuity 20/20 (uncorrected) OU. PERRL with white sclera bilaterally. Slight light sensitivity noted bilaterally. No crusting, lesions or masses on lids noted. Bilateral conjunctiva with diffuse redness and tearing but no mucoid or purulent drainage noted. No visible FBs under lids or on cornea to gross examination. Fundiscopic examination: Discs flat with sharp margins. Vessels present in all quadrants without crossing defects. Retinal background has even color, no hemorrhages noted. Macula has even color.
Ears	Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.
Nose	Nares patent. Nasal turbinates are pale and boggy with mild to moderate swelling. Nasal drainage is clear.
Throat	Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted.
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.

 

DQ2 Now, assume that any procedures and/or testing which were performed are NORMAL.

1. 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)

2. Identify the corresponding ICD-10 code.

3. Provide a treatment plan for this patient’s primary diagnosis which includes:

Medication*

Any additional testing necessary for this particular diagnosis*

Patient education

Referral

4. Provide an active problem list for this patient based on the information given in the case.

5. 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.

6. 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.