A 72-year-old woman presents to her regular primary care physician (PCP) with a 2-day history of fatigue, malaise, and fever.
Case Study #1
A 72-year-old woman presents to her regular primary care physician (PCP) with a 2-day history of fatigue, malaise, and fever. She awoke this morning with a dull ache in her right mid-back and some nausea. She came to the office because she is concerned about the pain and her worsening symptoms. She has been resting and taking acetaminophen (650 mg every 4 to 6 hours), which has helped with the fever and aches, but her symptoms return as the drug wears off. She is unsure of how high her fever has gotten. She states the pain is a 3 or 4 /10, however the fatigue, malaise, and nausea have kept her from her daily activities and caused her to remain in bed most of yesterday and all day today. She suspects she might have caught “the flu” though she received the vaccine 3 weeks ago. She is most concerned because she lives alone and is nervous of becoming seriously ill and having no way to call for help. She denies ever smoking and drinks a glass of wine only once or twice a month. Her husband of 50 years died 8 years ago of prostate cancer, and she lives independently in an apartment. One of her three children lives a few miles away and visits frequently. She is not currently sexually active.
She denies chills, night sweats, rhinorrhea, cough, shortness of breath, dyspnea, chest pains, palpitations, vomiting, diarrhea, or constipation. She admits to increased urinary frequency and urgency but denies pain with urination. She denies sick contacts or changes to her dietary routine.
Review of Symptoms and Relevant History
Positive for occasional knee pain. Her review of systems is negative for weakness, weight loss, focal pain except in the right flank, difficulty with memory or concentration, recent illness, or injury.
The patient’s history is significant for hypertension and osteoporosis. She has a family history of coronary artery disease (CAD). Her daughter lives nearby and is available to stay with her if needed.
Allergies: No medication, environmental, or food allergies
Current Meds: Lisinopril/hydrochlorothiazide 10/12.5 mg daily for hypertension, Alendronate 70 mg weekly for osteoporosis, Over-the-counter (OTC) calcium citrate 1,000 mg with 600 IU vitamin D3 daily for osteoporosis
Physical Exam Findings:
Vitals: T 38.8°C (101.8°F), P 96, R 14, BP 106/68, WT 56.7 kg (125 lbs), HT 172.72 cm (68 in.), BMI 20.2.
General: Ill and uncomfortable appearing, but non-toxic and without acute distress.
Psychiatric: Alert and oriented to person, place, and time; coherent conversation.
Skin, Nails: Skin pale and slightly flushed, no rash or lesion. Nails are smooth without hemorrhage.
HEENT: Eyes without retinal lesions; oral mucosa moist without lesions.
Chest: Symmetric excursion with no accessory muscle use.
Lungs: Resonant with vesicular breath sounds all fields; no wheezes, rales, or rhonchi.
Breasts: No mass or lesion bilaterally.
Heart: Quiet precordium; RSR; no murmur, rub, or gallop.
Abdomen: Flat, normoactive bowel sounds all quadrants, no mass. There is mild right costovertebral angle (CVA) tenderness and mild suprapubic discomfort but no tenderness.
Genital/Rectal: Vaginal and introital mucosa show atrophy. The uterus is small and smooth. No mass or lesion detected in the adnexa or cul-de-sac.
Musculoskeletal: No point tenderness detected on the vertebral processes.
Discussion:
1. Differential Diagnosis: Please list at least (and reference the background and pathophysiology with at least 2 sources) three differential diagnoses with the first diagnosis being your primary (most likely) diagnosis to demonstrate your understanding.
2. What if any diagnostic tests/imaging studies be ordered and Why? Consider testing in the Primary and Acute care setting as well.
3. Following these diagnostic tests as per above, what is the next step, explain based on your differentials what you plan to do next and why.
4. Review a recent and credible research article about the key factors (causes, risks, diagnostic testing, and treatment selection) of this primary diagnosis. Provide references for your response in APA format.
5. Patient education – Please document what is pertinent for education and why. For example, If smoking cessation is your plan for education, list why and how you will assist the patient with smoking cessation (i.e, referral or enrollment in group therapy, nicotine therapy, patches, Nicorette etc). Explain your education plan.
6. If not managed appropriately, what are the medical/legal concern(s) that may result from mismanagement?
7. List any collaborative opportunities. Provide a list of any specialties or other disciplines and indicate what contribution these professionals might make to managing the patient.
APA FORMAT, AND REFERENCES, scholarly resource cited in APA format from 2018-2023 only. (Within the last 5 years)
Please do not solely use a website as your scholarly reference, fine to use as supplement, but a journal article should be referenced or a text.
Please use reliable medical references such as your Goroll text, your Current Medical Diagnosis and Treatment book, or UpToDate. Do NOT use WebMD, Wikipedia etc. as these are not advance practice references.
APA format (if using outside sources).
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
