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
Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night
Characteristics
but does not feel well rested. "No energy to do anything I normally can do"
Aggravating
Exertion
factors
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)
Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months
Constitutional
ago.
Eyes No visual changes or diploplia
Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring
ENT
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
Reports worsening of depressive symptoms but thinks it is because she is so
Psych "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
Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium
Medications
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).
Maternal GM & GF deceased with CHF, T2DM and
HTN; Mother alive (age 82) +HTN, +Hyperlipidemia,
+T2DM;
FH
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.
Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally.
Throat
Teeth in good repair, no cavities.
Neck supple. No lymphadenopathy. Thyroid midline, small and firm
Neck
without palpable masses.
Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally.
Cardiopulmonary
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
1. Briefly and concisely summarize the 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.
Participation Guidelines
Enters initial post to part one by 11:59 p.m. MT on Tuesday; initial post to part two 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 in parts one and two, AND all direct faculty
questions in parts one and two by Sunday, 11:59 p.m. MT.
**To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of
the solid gray bar above the discussion board title and then Show Rubric.
This topic is closed for comments.
Search entries or author Filter replies by unreadUnreadCollapse replies Expand replies
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Collapse SubdiscussionJaemee Nguyen
Jaemee Nguyen
Aug 10, 2019Aug 10 at
11:37pm Manage Discussion
Entry Dr.Feehan and class,
Week 6: Clinical Case Study Part One Discussion
A 56-year-old Caucasian female patient complaints of progressively worsening
generalized constant fatigue for 2-3 months, 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."
Denies pain; missed 1 day of work 2 weeks ago because "couldn't get out of bed." 5
pounds weight gain in the last six months.
Sleeping 8-9hrs per night (no changes), but not feeling rested. Generalized
weakness and intermittent muscles cramping in calves.Her PMH includes; HTN,
depression, postmenopausal, tonsillectomy. Allergic to iodine dyes. Occasional glass
of wine (1-2 per month). Medications includes Multivitamin, B-Complex, Prozac
20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU. Temp-98.2,
P-74, R-16, BP 146/95, Height: 5'7", Weight: 180 pounds.
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
Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night
Characteristics
but does not feel well rested. "No energy to do anything I normally can do"
Aggravating
Exertion
factors
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)
Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months
Constitutional
ago.
Eyes No visual changes or diploplia
Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring
ENT
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
Reports worsening of depressive symptoms but thinks it is because she is so
Psych "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
Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium
Medications
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).
Maternal GM & GF deceased with CHF, T2DM and
HTN; Mother alive (age 82) +HTN, +Hyperlipidemia,
+T2DM;
FH
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.
Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally.
Throat
Teeth in good repair, no cavities.
Neck supple. No lymphadenopathy. Thyroid midline, small and firm
Neck
without palpable masses.
Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally.
Cardiopulmonary
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
1. Briefly and concisely summarize the 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.
Participation Guidelines
Enters initial post to part one by 11:59 p.m. MT on Tuesday; initial post to part two 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 in parts one and two, AND all direct faculty
questions in parts one and two by Sunday, 11:59 p.m. MT.
**To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of
the solid gray bar above the discussion board title and then Show Rubric.
This topic is closed for comments.
Search entries or author Filter replies by unreadUnreadCollapse replies Expand replies
•
Collapse SubdiscussionJaemee Nguyen
Jaemee Nguyen
Aug 10, 2019Aug 10 at
11:37pm Manage Discussion
Entry Dr.Feehan and class,
Week 6: Clinical Case Study Part One Discussion
A 56-year-old Caucasian female patient complaints of progressively worsening
generalized constant fatigue for 2-3 months, 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."
Denies pain; missed 1 day of work 2 weeks ago because "couldn't get out of bed." 5
pounds weight gain in the last six months.
Sleeping 8-9hrs per night (no changes), but not feeling rested. Generalized
weakness and intermittent muscles cramping in calves.Her PMH includes; HTN,
depression, postmenopausal, tonsillectomy. Allergic to iodine dyes. Occasional glass
of wine (1-2 per month). Medications includes Multivitamin, B-Complex, Prozac
20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU. Temp-98.2,
P-74, R-16, BP 146/95, Height: 5'7", Weight: 180 pounds.
