Hypertension & Type 2 Diabetes Differential Diagnoses
Directions: Be sure to review the Case Study 1 Grading Rubric for details on expectations of quality of answer. Read the case study and complete the answers in your own words to the ten questions below using the following guidelines: • Use complete sentences. • Use at least four sentences for each question. • Include an in-text citation at the end of each question. • Include at least four references with one being your textbook. No websites unless it is epocrates, uptodate or medscape, please use medical textbooks, and NP or MD journal articles. Note: Plagiarism or cut and paste from the internet will result in a zero for the assignment. Case Study for NP students A 38-year-old African American male presents to the clinic with mild headache, dizziness, and fatigue. He has not seen a health care provider in 8 years. He states that he is “tired of being tired all the time.” Weight: 240 lbs; Height 5’10”; waist to hip ratio > 2:1. He rates his headache 5/10 and describes as a constant, throbbing pressure distributed evenly over the top of his head. His symptoms are worse in the morning than evening. Tylenol and Ibuprofen help, pain is 2/10 after medication. He thinks he may have “blood pressure problems like his father”. He also reports increased thirst, hunger, and urination. Denies chest pain, injuries, physical trauma, or recent illness. His family history is positive for hypertension, coronary artery disease, and Type II Diabetes. Vital signs: HR 96, BP 160/86, RR 20, SpO2 98%. Psychosocial: sells insurance, occasionally feels stressed from work. Diet & Lifestyle: sedentary, frequently eats at local fast food restaurants. Denies tobacco use. Occasionally consumes alcohol, three or four times/year. Physical Exam: General: Alert & oriented to person, place, and time. Appropriately dressed & groomed with good hygiene. Calm & cooperative. Mental status: Oriented x3, speech appropriate, clear. HEENT: normocephalic, without deformities, no evidence of trauma. Hair with normal distribution & texture. Eyelids, sclera, and conjunctiva normal. PERRLA, EOM full, no cataracts, fundoscopic exam revealed mild nicking of retinal vessels and a few cotton wool spots. Ears w/normal appearing pinnae & auditory canals, tympanic membrane pearly gray, glistening, w/o retraction or bulging, normal light reflex, hearing intact. Nose without deformity, patent nares, pale pink, moist mucosa, normal turbinates, no deviation of septum or polyps noted. No tenderness to palpation of frontal or maxillary sinuses or nares. Buccal and tongue mucosa pink and moist. No lesions noted under tongue or inside mouth. Teeth in good repair, no evidence of gum disease. Tonsils not enlarged or red, oropharynx patent. Thyroid midline, no enlargement or nodularity present. No palpable lymph nodes in neck or supraclavicular fossa. No cervical masses. Trachea midline. Breasts, Axilla, Epitrochlear nodes: deferred. Cardiovascular: Carotids w/+3 pulses, no bruits. No JVD. Cardiac PMI in 5th intercostal space at midclavicular line. No lift or abnormal pulsations. S1&S2 present w/normal quality. No murmurs, gallops, or clicks noted. +2 peripheral pulses, normal rate & rhythm. Chest & Lungs: clear in upper & lower fields. No fremitus. No pectus excavatum or carinatum present. Normal respiratory pattern, inhalation & expiration full without use of accessory muscles. A-P diameter 2:1. No deformities of thorax seen. Abdomen: Normal bowel sounds, soft, nondistended, nontender. Liver, kidneys, spleen not palpable. Aortic pulsation palpable within normal limits. Back: no scoliosis, kyphosis, or lordosis seen. No CVA tenderness. Extremities: Acanthosis nigricans noted around neck and under arms. Skin warm & dry. No abnormal lesions noted. Mild, non-pitting edema to and hands and feet. Normal venous pattern. No varicosities seen. Genitals: deferred. Rectal: deferred. Musculoskeletal: Full ROM, no joint/extremity deformities, Neuro: cranial nerves intact, DTR’s +2, negative Homan’s sign. No ankle clonus. Motor intact, no focal weakness, normal muscle tone. Coordination: smooth, coordinated movements. Sensation: intact to pain, light touch, proprioception & vibration. No graphesthesia or stereognosis. Complete the following questions. 1. List the top three differential diagnoses with rationale for each. 2. For each diagnosis list and describe diagnostics/laboratory analysis and/or other assessments that should be ordered to confirm the diagnosis. 3. Based upon Mr. Jones history and your differential diagnoses, what clinical syndrome is Mr. Jones high risk for? Describe the criteria for this syndrome. 4. Describe the basic pathophysiology of this syndrome. 5. What are the most serious complications of the top differential diagnosis and the clinical syndrome in question 4. 6. What is treatment and management for top differential diagnosis and the clinical syndrome described in question 2 above.
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