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Module 3 Case Study A 78-year-old old female (Judy) presents to…
Module 3 Case Study
A 78-year-old old female (Judy) presents to your primary care clinic with the chief complaint of feeling very tired lately. She also is having nasal congestion. Her daughter is with her today and says she has been more fatigued for the last year. Daughter also reports her mother seems to have some confusion, poor appetite, and complaints of a bitter taste in her mouth. Judy eats three meal a day – no red meat and has lost about 6 pounds in the last couple months. She denies nausea, vomiting or abdominal discomfort. Bowel movements are consistent daily with formed stool.
Past Medical History: significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus all were diagnosed 8 years ago. Reports having been told she has “Mediterranean anemia” several years ago. Had bilateral cataract removal 4 years ago. Follows with Ophthalmology every six months and Podiatry every three months. Last routine medical exam was 9 months ago at another facility.
Family Medical History: Mother deceased (age 81) – DM Type 2 & hypertension. Father deceased (age 84) – lung cancer.
Social History: nonsmoker – quit a pack a day habit 30 years ago; denies ETOH use or history of substance abuse; Does not exercise – mostly watches TV. Lives in an adult community in her own one-story home. Has house help come 3 times a week. She is a retired restaurant cook. Her daughter lives nearby.
Medications: NKA. Glucophage 1000 mg twice a day; Avandia 4 mg daily; Protonix 40 mg daily; Aricept 10 mg at night; Cardia 240 mg daily in am; Lisinopril 10 mg daily; Diovan 160/12.5 twice a day; Crestor 5 mg daily; Zetia 10 mg daily; Coreg 12.5 mg twice a day; Lasix 20 mg daily; Potassium 10mEq daily; Actonel 35 mg weekly; Multivitamin; B12 vitamin.
Allergies: NKA & is up to date on immunizations
Review of Systems – Subjective:
Skin: complains of dry skin
HEENT: Denies dizziness, vision changes or headache
Cardiovascular: Denies chest discomfort, palpitations,
Respiratory: Reports occasional cough and noticed more shortness of breath recently. Sleeps on 2 pillows.
Gastrointestinal: denies abdominal pain, bloating, nausea, or vomiting. States BMs are daily, normal brown in color & consistency. Denies change in bowel pattern.
Musculoskeletal: reports occasional joint pain in her right knee – had replacement 10 years ago.
Psych: alert and oriented x3; interactive. States just is more tired and weak.
Physical Exam – Objective
Vitals: T: 98.2 P: 86 RR: 28 SaO2: 93; BP 140/70 Wt: 191 Ht: 64 inches
Skin: Clear, slightly grayish color
HEENT: Hair thinning & gray in color. Sclera nonicteric, PERLA< Oral mucosa pink & moist. Neck: no JVD, no bruits, thyroid nonpalpable, no lymphadenopathy Cardiovascular: regular rate & rhythm, + systolic murmur II/VIs, pulses positive in all extremities, bilateral non-pitting edema in lower extremities, chronic lymphedema bilaterally, no ulcerations , skin intact, no hair growth. Respiratory: lungs clear bilaterally; transverse/AP diameter 2/1 Abdomen: obese contour, soft, nontender, BS in all quadrants, no organomegaly or bruits Musculoskeletal: Walks with a cane, full ROM, no deformities, strength appropriate for age. Skin: without any current suspicious lesions , rashes, or ulcers. Neurological: Alert, interactive & oriented x3; CN I-XII grossly intact. No evidence of depression on assessment score. Point of care lab testing done at clinic - significant findings were: CBC: Hgb: 10.1; HCT: 29.5; FBS: 149; HbA1c: 7.2; K: 4.8; BUN: 42; Creat: 1.44; GFR: 35 Please answer the following questions: What are your top four (4) differential diagnoses? What is the most likely diagnosis and why? What is your treatment plan? What is your plan of follow-up care? Are there any standardized guidelines that you should use to assess and treat this patient?
