NR511 Week 6 Discussion (dq1+dq2) Latest 2020 MAY

NR511 Differential Diagnosis and Primary Care

Week 6 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. (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.

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

 

DQ2 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 THURSDAY; 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 THURSDAY 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:

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)