1. A 45 yo diabetic female complains of recurrent whitish vaginal discharge with itching.
1. A 45 yo diabetic female complains of recurrent whitish vaginal discharge with itching. Patient is not sexually active and denies the possibility of STIs. She reports that she has been diagnosed with vaginal candidiasis 5x already for the past 6 months. Patient has always been treated with one time Diflucan which affords relief albeit temporarily. How would you proceed with the treatment during today’s visit?
2.Case Study Chosen: Case study #3
Demographics: 56 Y/O MALE
SUBJECTIVE
CC: “My mental status has declined over the last several months. I first developed numbness in my finger tips and balls of my feet but now it has progressed to a decrease in overall motor control of my hands causing me to drop objects, or flinging objects when trying to pick them up. I also have been experiencing visual tracking problems that have caused issues with driving, and I have noticed memory loss.”
HPI: 56 y/o male pt presenting to the clinic with decreased mental status over the last several months accompanied by numbness in fingertips and balls of feet. Pt ℅ decreased motor control of hands, and visual disturbance with increased memory loss.
O- When did you first start noticing a decline in motor control and numbness in your hands and feet? When did you start noticing a problem with driving? When did you start noticing visual disturbance? When did you start noticing a decrease in memory?
L- Where in the body are you feeling numbness or motor control loss?
D- How long have you noticed these symptoms?
C- Do you have any other symptoms related to this issue?
A- Does anything make your symptoms worse that you have noticed?
R- Have you tried anything to relieve your symptoms?
T- Have you tried anything on your own to treat this condition? Have you taken any medications? If yes, what, and how long did you take it and how frequent were you taking it? Did it resolve any of the symptoms or decrease the severity?
S- Do you feel like the motor skills, numbness and memory loss is getting better or worse? Do you feel like this is affecting any other part of the body? Is there anyone that you have in your family who suffers from this?
Past medical hx: Do you have any past medical hx?
Past surgical Hx: Do you have any past surgical hx? If so, what are the dates of the surgeries?
Family hx? Do you have any family history on either side (mother/father)?
Current Medications: Are you currently taking any medications other than the antacid post meal? Are you taking any OTC pain relievers, or OTC supplements?
Allergies: Do you have any medication, food, or chemical allergies? If so, what is the reaction?
Immunization hx: Do you currently have all of your up-to-date immunizations including flu, covid-19 + boosters?
Health Maintenance: When was your last dental, eye, physical examination?
Social HX: Are you currently employed? What are your eating habits? Do you smoke tobacco products, drink alcohol, or use illicit drugs? Where are you currently living? Who do you live with? Are you married, single? Are you sexually active?
Subjective:
General: Are you experiencing any malaise, weakness, fever, or chills? Have you noticed a change in your weight over the last 6 months?
Neurological: (+) Numbness of fingers, and balls of feet, (+) for change in memory. Are you experiencing any headaches, hx of head injury or loss of consciousness, lightheadedness, dizziness or vertigo? Are you having trouble sleeping? Persistent thoughts or worries? Decrease in sexual desire, abnormal thoughts, visual or auditory hallucinations. Are you having a history of psychosis or schizophrenia? Are you having difficulty concentrating ?
Cardiovascular: Have you noticed SOB? Are you experiencing any chest discomfort, heaviness, or tightness? Have you noticed any abnormal heartbeat or palpitations? Are you having to sleep elevated on 2 pillows or more? Have you noticed any swelling of the feet? Have you passed out or have been feeling like you were going to pass out? Do you have a history of heart attacks or heart failure?
Respiratory: Are you experiencing a cough? Do you have any phlegm production, coughing up blood, wheezing, sleep apnea, exposure to inhaled substances in the workplace or home? Have you been exposed to TB or have you traveled outside the country? Do you have a history of asthma, COPD/Emphysema or any other chronic pulmonary disease?
Musculoskeletal: Do you have any muscle or joint pain, back or neck pain? Do you have recent accidents or injuries? Do you have a condition that limits activities or ADLS?
OBJECTIVE
General:
BP:117/70
HR: 72
Temp: 98.6
RR: 12
Ht 5’9” Wt 193 lbs.
BMI: 28.5
Physical Exam Elements:
General: (+) Malnourished. Vital signs are stable, in no acute distress. Alert, well developed.
Neurological: Assess cranial nerves. Assess DTRS. Assess sensation to touch, and motor/sensory deficit.
Cardiovascular: Listen to the heart. Listen for S1, S2 and ensure no murmurs, rubs or gallops appreciated.
Respiratory: Listen to lung sounds, observe chest rise and fall.
Musculoskeletal: Assess for ROM in the neck and arms, for any stiffness, pain, or muscle tightness. Assess balance and gait. Assess gait and station. Assess muscle strength and tone 5/5 in all groups. Assess for equal arm swing.
POC Testing: N/A in clinic need to refer patient out for repeat labs
ASSESSMENT
Working Diagnosis:
Vitamin B12 Deficiency (D51.9)
(+) pins and needles (paraesthesia)
(+) Disturbed vision
(+)changes in the way that you walk and move around.
(+) fatigue
(+) muscle weakness
(-) Depression
(-) Irritability
(-) a sore and red tongue (glossitis)
B12 deficiency manifests as macrocytic anemia, and thus, the presenting symptoms often include signs of anemia, such as fatigue and pallor. Due to the increased hemolysis caused by impaired red blood cell formation, jaundice may also be a presenting symptom (Langan, 2020).
Differential Diagnosis:
Multiple Sclerosis (MS) (G35)
(+) Numbness and tingling
(+) fatigue
(+) loss of balance
(-) bowel trouble
(-) bladder trouble
(-) spasms
Nerve root compression/Pinched nerve (G55)
(+)Tingling or numbness
(+)Weakness of muscles.
(-)Pain in the back, neck, and limbs
(-) Frequent feeling that a foot or hand has “fallen asleep”
(-)Sharp, aching or burning pain, which may radiate outward.
PLAN
Diagnostic studies:
Serum B12 measurement and a complete blood count (CBC).
MMA and homocysteine levels should also be measured to confirm.
(NHS, 2023).
Treatment: Pt to receive b12 injection (hydroxocobalamin) in office every other day until symptoms begin to improve. Then patients can get b12 injections every week or move to oral supplements. Oral and injectable vitamin B12 are effective means of replacement, but injectable therapy leads to more rapid improvement and should be considered in patients with severe deficiency or severe neurologic symptoms (Langan, 2020).
Referrals: Refer patient out to a
Hematologist
Gastroenterologist
Dietitian.
Education:
Good sources of vitamin B12 include: meat, salmon + cod, milk and other dairy products, and eggs!
Work with a nutritionist or dietitian to help get more vitamin B12 from food.
Understand you will probably need to take the supplements for the rest of your life. Refrain from driving.
Health maintenance:
Eye exam (yearly)
Colonoscopy (Q10 years w/ no hx).
PSA (Q2 years).
Dexa Scan (70+ years old)
Diet/Lifestyle changes
Vaccines
COVID-19 w/ boosters in 2022.
Influenza (declines)
RTC: Repeat blood work within 7-10s after starting IM injections of hydroxocobalamin. F/U in office in 2 weeks to go over blood work. Plan to repeat labs 8 weeks after this and ensure f/u with referrals.
3. Case Study #2 Week 6
#2 Tim is a 22 y/o male who is complaining of lethargy, cold sensitivity, weight gain of 10 lbs over the last 3 months with an unnoticeable change in appetite, brain fog, constipation, and muscle weakness that he feels has become progressively more noticeable over the last several months. Tim is a heterosexual, single, full-time college student and works part-time at a coffee shop. His last annual physical examination was 2 years ago and was WNL. His current vital signs are 110/70, 62, 98.6, 12, Ht 5’9” Wt 190 lbs.
Demographics: Age/Gender
22-year-old/Male
SUBJECTIVE
CC: “I feel lethargic, have cold sensitivity, gained over 10 pounds in weight in the last 3 months, experiencing changes in appetite, brain fog, constipation, and muscle weakness that has gotten progressively worse over the last several months.”
HPI: The patient states that over the past few months, he has been feeling a multitude of different symptoms, including lethargy, sensitivity to colds, weight gain (10 pounds over the last 3 months) with a noticeable change in his appetite, constipation, and muscle weakness. No particular location has been the issue’s focus (more systemically). He has not been doing anything to aggravate or relieve the factors.
Past Medical History
Medical/Surgical
None
Hospitalizations
Broken Leg in 6th grade
Medication
Over the Counter
Tylenol is needed for headache or pain 500mg PRN Q6H
Allergies
None
Immunizations
COVID 19’ (Booster 2023)
Flu (2022)
Preventative Health Maintenance
None
Family History
Maternal (Age 50)
None
Fraternal (Age 56)
Hypertension
Sister (Age 25)
None
Social History
Nutrition
Regular Diet
Exercise
Plays soccer with his dormmates on the weekend
Sexual History
Single, not in a monogamous relationship
Occupation
Full-Time Student and Part-Time worker at a coffee shop
School
In college for Business
Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).
General
Do you have a family history of thyroid disease?
Do you have trouble sleeping?
How much weight have you gained?
Have you ever had radiation in the neck?
HEENT
Have you ever experienced a goiter?
Does your voice have a hoarseness to it?
Have you noticed pain or enlargement in your neck?
Cardiovascular
Have you experienced a lower heart rate?
Respiratory
Do you have difficulty breathing?
Do you often get shortness of breath?
Gastrointestinal
Do you experience constipation?
Skin & Breast
Do you experience dry skin?
Musculoskeletal
Do you experience muscle cramps?
Do you experience body weakness?
Do you experience any swelling?
Allergic
Any allergies?
Immunologic
Do you have an autoimmune disease
Endocrine/Lymphatic
Do you have any endocrine diagnosis?
Genitourinary
N/A
Neurological
Do you experience headaches?
Psychiatric/Medical
N/A
ROS
General
Reports feeling lethargic and having cold sensitivity. Reports gaining 10 pounds over the past 3 months that has not been unnoticeable in a change in appetite. Reports having brain fog and has noticed these issues over the past several months.
HEENT
Reports having hoarseness when speaking. Declines choking, dry mouth, or dental carries. Declines change in vision, eye pain, sensitivity, or discharge. Declines ear pain, loss/decrease in hearing, ear ringing, or ear drainage. Declines in senses of smell, nose bleeds, or sinus/facial pain. Declines difficulty chewing or swallowing.
Cardiovascular
Declines chest pain, tightness, or heaviness. Declines heartbeat or palpations.
Respiratory
Declines shortness of breath or difficulty sleeping. Declines coughing or phlegm production. Declines wheezing, crackles, or rhonchi.
Gastrointestinal
Reports constipation and unnoticeable changes in appetite. Reports 10 pounds of weight gain in the last 3 months. Declines diarrhea. Declines blood in the stool. Declines hemorrhoids or trouble swallowing. Declines nausea and vomiting. Declines abdominal discomfort/pain.
Skin & Breast
Reports having cold sensitivity. Declines rashes, itching, or abnormal skin injury.
Musculoskeletal
Reports feeling muscle weakness that has become progressively more noticeable over the last several months. Declines recent accidents or injuries. Declines physical disabilities or conditions that limit ADLs.
Allergic
Declines any allergies, including medication or seasonal allergies.
Immunologic
Declines history of HIV, TB, hepatitis, or Herpes Zoster. Declines history of cancer or radiation or chemotherapy.
Endocrine/Lymphatic
Reports cold sensitivity. Declines history of Diabetes Type 1 or 2. Declines instability of blood sugars.
Genitourinary
N/A
Neurological
Reports experiencing brain fog. Declines history of head injury or loss of consciousness. Declines lightheadedness, dizziness, or vertigo. Declines previous strokes, seizures, or neurological issues.
Psychiatric/Medical
N/A
OBJECTIVE
General:
VS BP, HR, RR, Weight, Height, BMI
Blood Pressure: 110/70
Temperature: 98.6F
Heart Rate: 55
Respiration: 12
Weight: 190 lbs / Weight prior 175 (3 months ago)
Height: 5’9”
BMI: 28.1
Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)
Head: Positive for dry, coarse hair and thinning of the eyebrows. Positive for facial puffiness. The head is atraumatic and normocephalic.
Eyes: Positive for periorbital edema and puffy eyes. The sclera is white, and the conjunctive and lashes are clear. No lid lag noted.
Ears: Ears are clear with your cerumen. TM is clear and pearly gray.
Nose: Patent and mucosa is pink, moist, and intact.
Throat/Mouth: Positive for hoarseness in voice noted. Positive for enlarged tongue. Mouth and lips were intact with no lesions. Good dentition. Hard/Soft palates intact. The tongue and uvula are midline. No goiter noted.
N/A
Unlabored Breathing. The chest was equal and symmetrical rise. No adventitious breath sounds were heard.
Bradycardia noted. S1/S2 without murmur, gallops, and rubs.
Hypoactive bowel sounds were noted. No hetosplenomegaly on exam. No tenderness or masses were noted.
No lymph nodes or glands on the neck, axilla, or groin were noted.
Positive for muscle weakness, noted bilaterally. +4/5 noted on lower and upper extremities.
Positive for dry, thick, coarse skin. Positive for brittle nails. No rashes, lesions, or masses were noted.
No cyanosis or clubbing were noted. No edema noted on extremities noted. Pulses +2 bilaterally on radial and pedal pulses.
Positive for slower speech, hyporeflexia, and bradykinesia. Cranial nerves intact II-XII.
Mood and affect were appropriate during the visit. Judgment and insight were within normal limits at this time.
General Appearance: Appearance is lethargic but is alert and oriented x3. Weight gain noted from previous 15lbs on record.
HEENT:
Neck:
Respiratory
Cardiovascular
GI
Lymph Nodes
Musculoskeletal
Integumentary
Extremities
Neurology
Psych
POC Testing (any Point of Care (POC) testing specifically performed in the office): What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.
Not Applicable
ASSESSMENT
Working Diagnosis: (Must include ICD 10)
Hypothyroidism happens when the thyroid gland does not make enough thyroid hormone. The severity of hypothyroidism is dependent on the severity of the conditions that can develop. Symptoms include tiredness, sensitivity to colds, constipation, goiter, dry skin, and others (Ross, 2022).
Hypothyroidism
ICD 10: E03.9
Differential Diagnosis:
Pertinent Positive: “presents similar to no difference except lab results.” Similarities are fatigue, tiredness, body weaknesses, constipation, intolerance to cold, puffiness in the face, and weight gain.
Pertinent Negative: Acute illness, not considered to be a thyroid disorder. It is a change in thyroid levels due to another illness (**While clinical hypothyroidism is more chronic)
Why Not? ESS has low, normal, or slightly elevated TSH levels, unlike the significance of clinical hypothyroidism.
Pertinent Positive: Weakness, tiredness, irritability, headaches.
Pertinent Negative: Loss in appetite, numbness or tingling of hands and feet, shortness of breath, and pale color.
Why Not? Labs results will show which diagnosis would be better suited for the patient. CBC, TSH, T3, and T4 should be ordered so that differentials can be ruled out of the working diagnosis.
**Due to the subtle symptoms of the disease, many of the prognosis is based on a laboratory basis.
Euthyroid Sick Syndrome (ESS) (Shomon, 2023).
ICD-10: E07.81
Anemia (Means & Brodsk, 2022).
ICD-10: D64.9
PLAN
Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.
**for hypothyroidism TSH (increased); T4/T3 (decreased)
TSH, T4, T3 (Ross, 2022).
Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.
Goals of Treatment: (Ross, 2023).
Relieve Symptoms
Normalize TSH
Reduction of Goiter if present
Avoid Overtreatment
Prescription Drugs (Woo & Robinson, 2019).
Synthetic Thyroxine
Name: levothyroxine
Dosage: 50mcg-125mcg (This patient 125mcg/day)
Frequency: QAM before breakfast
Duration: QDaily
Number of Tabs: 30 tabs
Refills: 3
Referrals (Ross, 2023).
If unable to manage after 6 months, will be referred to an Endocrinologist
Endocrinologist Referral: 22-year-old male diagnosed with hypothyroidism. The patient is on 125mcg of Levothyroxine QDaily AM. Patients persist with hypothyroid symptoms even with medication, so I have referred him to your services for assistance in managing his condition.
Education (Ross, 2023).
Levothyroxine is very important with the dosage timing; take on an empty stomach with water 30-60 minutes before breakfast.
It can take 2-4 weeks to improve symptoms and several months to treat severe hypothyroidism.
Health maintenance (Cedars Sinai, n.d.).
Since the patient is a young college student, health maintenance may be needed for:
Alcohol Misuse
Depression
Diet and Exercise
Smoking/Drugs
STI
Vaccines
Flu
COVID (patient is UpToDate)
RTC (Ross, 2023). (Dunphy et al., 2022).
Schedule for lab draw and clinic appointment with the primary provider 4-6 weeks after the start of medication for possible adjustments to medicines based on laboratory result
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