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: PLANDiagnostic 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 ResultsHemoglobin(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)PlasmaHomocysteine11 ?mol/L (5–15 ?mol/L)Anti-intrinsic factor (anti-IF) antibody1.0 (0-1.1 Unit)Acetylcholine Receptor (AChR) binding antibodiesnegative (?0.02 nmol/L)Head computed topography (CT)No cerebral atrophy or white matter changes consistent with demyelinationTable 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. DiagnosisSigns/SymptomsGold Standard DiagnosticsGold Standard TreatmentHyperthyroidismGrave’s DiseaseHypothyroidismHoshimoto’s ThyroiditisAddison’s DiseaseCushing’sDiabetes Mellitus Type 1Diabetes Mellitus Type 2Hyperprolactinemia*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.DiagnosisSigns/SymptomsGold Standard DiagnosticsGold Standard TreatmentIron Deficiency AnemiaThalassemia MinorAplastic AnemiaPernicious AnemiaVitamin B12 DeficiencyNon-Hodgkin’s LymphomaMultiple MyelomaThrombocytopeniaFolic Acid DeficiencyNeutropeniaHodgkin’s Lymphoma
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:
•
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
PLAN
•
•
•
•
Education:
Health maintenance:
RTC:
Week 6 Endocrine/Metabolic/Hematological Discussion Prompts
1. 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 fulltime 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,
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, fulltime 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.
3. 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
15 g/dL (13.5 to 17.5 g/dL)
(Hgb)
Hematocrit
45% (41-50%)
(Hct)
Mean Corpuscular
Volume (MCV)
Serum Vitamin B12
(cobalamin)
Serum
Methylmalonic Acid
(MMA)
Plasma
Homocysteine
Anti-intrinsic factor
(anti-IF) antibody
Acetylcholine
Receptor (AChR)
binding antibodies
Head computed
topography (CT)
93 fL (80-100 fL)
175 pg/mL (200-910 pg/mL)
6434 nmol/L (0-400 nmol/L)
11 ?mol/L (5–15 ?mol/L)
1.0 (0-1.1 Unit)
negative (?0.02 nmol/L)
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
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).
Gold Standa
•
•
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
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
Signs/Symptoms
Gold Standard Diagnostics
Gold Standa