- 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.
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”|
|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”|
|Relieving factors||None identified|
|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|
This is a 56 yo white female, with CC of fatigue that started 2-3 months ago, it is generalized and constant, and is progressively worse, she feels tired all the time, sleeps 8 hrs but does not feel rested. Exertion makes it worse with no relieving factors, she has not tried any treatments, and it is getting so bad that she has missed work because she “couldn’t get out of bed.” No recent illness, does have 5lb weight gain since last visit 6mos ago. She is having constipation and cold intolerance. She reports depressive symptoms due to lack of productivity but denies suicidal thoughts, also has generalized weakness and intermittent muscle cramping in the calves. She has PMH of HTN, Depression, Postmenopausal x5 years. PSH tonsillectomy, Allergies to Iodine dyes, denies cigarette or drug use, drinks wine 1-2x per month. She is A&Ox4, VSS, with negative physical exam except her skin is dry and her hair is thick and coarse….Kindly click the purchase icon to purchase the full solution at $10