Setting: large urban city family practice clinic which employs physicians and nurse practitioners.
Your next room has 2 charts in the box. It is the mother and son of a family that you know well. You review the chart before entering the room to familiarize yourself with these patients. Both present today with complaints of fatigue.
When you enter the room you see a woman who appears her stated age sitting in the chair and a boy who looks about 10 years old sitting on the exam table. You introduce yourself as you always do and ask what brings them both in to see you today.
Mary states, “We have both been usually tired. I have noticed Michael has not been himself for a few weeks, maybe more. He had a cold like rest of the family had but he just seemed to have it worse. He seems to have no energy, is never hungry anymore and has lost some weight. He seems to be always thirsty and he actually wet the bed last week. He has been sleeping more but I thought maybe he was growing”
Mary states “I have not felt like I had any energy since I got that cold about 6 weeks ago. I am always tired and my eyes are always puffy. I know I have a really busy life but I am more tired than usual. I come home from work and I just want to go to bed. I’m cold all the time and I seem to be having more headaches too”
Michael:
PMH
Mother reports general health as good: no childhood or chronic illnesses. Surgeries: none. Hospitalizations: none. Immunizations: UTD: allergies: Penicillin, gets a rash no ETOH, tobacco, illicit drugs. Sleeping 8-10 hours a night. Medications: daily multivitamin
Social History
Good student, oldest of four children. Lives with parents, grandparents and siblings. Have 2 dogs and a cat.
Family History
Parents and siblings are in good health,MGM: HTN and hyperlipidemia. MGF: HTN and hyperlipidemia. Paternal grandparents deceased: PGM: brain Ca, PGF: leukemia
Mary
PMH
Reports overall good health. Denied past illness or injuries. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex vitamin.
Social
Married, high school graduate, works full time at a local business in the ordering department. Lives with husband, children and parents. Husband and father both smoke but not in the house.
Family
Mary has 2 siblings who are in good health.&; Mother has HTN and hyperlipidemia. Father has HTN and hyperlipidemia.
Discussion Part One:
- What further questions do you have forMichael or his mother at this visit? Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
- What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
- Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
- What further questions do you have forMary at this visit?&; Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
- What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
- Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
ScholarMatic: Explanation & Answer
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