Week 6: Clinical Case Study Part One Discussion
Week 6: Clinical Case Study Part One Discussion
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 comparing and contrasting the possibilities. Use pertinent positive and negative findings to argue for or against each diagnosis in your differential. Rank your diagnoses in order of most likely to least likely with EBM references.
- 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
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Week 6: Clinical Case Study Part One Discussion
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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 |
Week 6: Clinical Case Study Part One Discussion
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
- Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
- Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
- One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
- I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
- Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
- In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
- Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
- Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
- Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
- Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
- I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
- I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
- As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
- It is best to paraphrase content and cite your source.
LopesWrite Policy
- For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
- Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
- Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
- Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
- The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
- Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
- If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
- I do not accept assignments that are two or more weeks late unless we have worked out an extension.
- As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
- Communication is so very important. There are multiple ways to communicate with me:
- Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
- Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
