Template Case Study Chosen: (List what case you have chosen) Demographics: Age/Gender SUBJECTIVE ...
Template Case Study Chosen: (List what case you have chosen) Demographics: Age/Gender SUBJECTIVE CC: HPI: (As listed from Case Study Information) 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). OBJECTIVE General: VS BP, HR, RR, Weight, Height, BMI 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.) 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. ASSESSMENT Working Diagnosis: (Must include ICD 10) Differential Diagnosis: 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. 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. Referrals: If Applicable Education: Health maintenance: RTC: Week 6 Endocrine/Metabolic/Hematological Discussion Prompts Maria is a 35 y/o female who is complaining of frequent vaginal yeast infections. She has had 4 in the last 6 months, and they have been treated with topical and oral antifungal medications which have initially worked, but the infections recur within 1-2 weeks. Maria reports increased thirst and urination for the last two to three months. Maria is an office manager in a bookstore who works full-time and has 4 children aged 5, 7, 10, and 12, who live with her 80% of the time. She has been divorced x 3 years and is struggling to make ends meet and reports she and her children frequently eat fast food because of the low cost and time constraints. Maria’s vital signs are 136/88, 98.8, 16, 80, Ht 5’3”, Wt 187 lbs,?? 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.? Brian is a previously healthy 56-year-old white man who presents with progressive neuropathy and declining mental status over several months. The patient initially developed numbness of his fingertips and the balls of his feet and began to lose motor control of his hands, which manifested as dropping objects or flinging them as he tried to pick them up. As symptoms progressed, he had visual tracking problems that were severe enough to interfere with driving a car, and he developed short-term memory loss and slowing of cognitive function. His current vital signs are 117/70, 72, 98.6, 12, Ht 5’9” Wt 193 lbs. Brian's Laboratory Results Hemoglobin (Hgb) 15 g/dL (13.5 to 17.5 g/dL) Hematocrit (Hct) 45% (41-50%) Mean Corpuscular Volume (MCV) 93 fL (80-100 fL) Serum Vitamin B12 (cobalamin) 175 pg/mL (200-910 pg/mL) Serum Methylmalonic Acid (MMA) 6434 nmol/L (0-400 nmol/L) Plasma Homocysteine 11 ?mol/L (5–15 ?mol/L) Anti-intrinsic factor (anti-IF) antibody 1.0 (0-1.1 Unit) Acetylcholine Receptor (AChR) binding antibodies negative (?0.02 nmol/L) Head computed topography (CT) No cerebral atrophy or white matter changes consistent with demyelination Table 1. Common Endocrine and Metabolic Disorders. Complete Table 1 if you chose case study #1 or #2. In addition to your SOAP note, you must also complete the following table. Upload your SOAP note and table to the discussion board. Diagnosis Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment Hyperthyroidism Grave's Disease Hypothyroidism Hoshimoto's Thyroiditis Addison's Disease Cushing's Diabetes Mellitus Type 1 Diabetes Mellitus Type 2 Hyperprolactinemia *Exam Tip First-line medication for type 2 DM is metformin (Glucophage). If patient on metformin 500 mg daily and A1C is high (>7%), increase dose to metformin 500 mg BID. If A1C is still high (>7%) and on metformin 500 mg BID, increase dose to metformin 1,000 mg BID (or 1 g BID). If taking maximum dose of metformin (1 g BID), can use several drug classes with it such as a sulfonylurea like glipizide (Glucotrol XL) 5 mg PO daily (do not exceed maximum dose of glipizide 20 mg/day), DPP-4 inhibitor (Januvia, Onglyza), TZDs (Actos), others. Table 2. Common Hematologic Disorders. Complete Table 2 if you chose case study #3. In addition to your SOAP note, you must also complete the following table. Upload your SOAP note and table to the discussion board. Diagnosis Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment Iron Deficiency Anemia Thalassemia Minor Aplastic Anemia Pernicious Anemia Vitamin B12 Deficiency Non-Hodgkin's Lymphoma Multiple Myeloma Thrombocytopenia Folic Acid Deficiency Neutropenia Hodgkin's Lymphoma
