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.

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.

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. 150 150 Nyagu

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: 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

**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.

DISCUSSION CONTENT

Category

Points

%

Description
Application of Course Knowledge

15

30%

A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND
Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND
A brief statement of pathophysiology is included for each diagnosis; AND
Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND
The differential is ranked in order from most likely to least likely; AND
Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND
Testing decisions are well supported with EBM arguments that are in-line with the clinical scenario and appropriate for the primary care setting
(7 critical elements)

Support from Evidence-Based Practice (EBP)

15

30%

Discussion post is supported with appropriate, scholarly sources; AND
Sources are published within the last 5 years (unless it is the most current CPG); AND
Reference list is provided and in-text citations match; AND
All testing decisions are fully supported with an appropriate EBM argument
(4 critical elements)

Interactive Dialogue

10

20%

Student provides a substantive* response to at least one topic-related post of a peer; AND
Evidence from appropriate scholarly sources are included; AND
Reference list is provided and in-text citations match; AND
Student responds to all direct faculty questions

(*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response

(4 critical elements)

Total CONTENT Points= 40 pts

DISCUSSION FORMAT

Category

Points

%

Description

Organization

5

10%

Case study response is presented in a logical format, AND
Responses are in sequence with the numbered questions AND
The case study response is understandable and easy to follow AND
All responses are relevant to the case topic
(4 critical elements)

Grammar, Syntax, Spelling & Punctuation

5

10%

Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors*