(SOLUTION) NR511 Week 6: Clinical Case Study Part One Discussion

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:

  1. 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. 

Total Points Possible:  50 

Requirements:

  1. 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.
  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 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  % 
  1. Description 
Application of Course Knowledge  15  30% 
  1. A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND
  2. Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND
  3. A brief statement of pathophysiology is included for each diagnosis; AND
  4. Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND
  5. The differential is ranked in order from most likely to least likely; AND
  6. Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND
  7. 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% 
  1. Discussion post is supported with appropriate, scholarly sources; AND  
  2. Sources are published within the last 5 years (unless it is the most current CPG); AND 
  3. Reference list is provided and in-text citations match; AND 
  4. All testing decisions are fully supported with an appropriate EBM argument 

(4 critical elements) 
Interactive Dialogue  10  20% 
  1. Student provides a substantive* response to at least one topic-related post of a peer; AND 
  2. Evidence from appropriate scholarly sources are included; AND 
  3. Reference list is provided and in-text citations match; AND 
  4. 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% 
  1. Case study response is presented in a logical format, AND 
  2. Responses are in sequence with the numbered questions AND 
  3. The case study response is understandable and easy to follow AND 
  4. 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* 

 
      Total FORMAT Points= 10 pts 
      DISCUSSION TOTAL= 50 pts 

SOLUTION

A 56-year-old Caucasian female affected person issues of steadily worsening generalized consistent fatigue for 2 3 weeks, seems exhausted all the time, sleeps 8hrs every night but doesn’t look nicely rested. “No power to do something I usually could do.” Denies pain; missed one day of labor two weeks ago because “could n’t get from bed.” five lbs weight gain within the last 6 weeks. Sleeping 8 9hrs every night (no changes), however, not feeling rested. Generalized weakness and even intermittent muscles cramping inside calves.Her PMH includes; HTN, postmenopausal, depression, tonsillectomy. Allergic to iodine dyes. Occasional cup of wine (1 2 per month). Multivitamin is included by medications, 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 lbs.

Bodily assessment finding that’re important to medical diagnosis includes: Thyroid little and tight with no palpable masses; epidermis all round dry, hair rough as well as heavy, nails without ridging, pitting or maybe discoloration; DTRs 1+ at ankles and knees. The individual denies any complaints and sleep disorders of sleep apnea that also rules out the root cause of the chief complaint of her.

Along with the collected material I’ve determined the following differential diagnoses as a way as most probable to minimum likely.

1.Hypothyroidism

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