NR511 week 6 -Discussion 1 and 2 - April 2018

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Dated: 11th Jul'18 09:12 AM
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dq 1

Week 6: Discussion Part One

33 unread replies.2727 replies.

Date of visit: November 7, 2017

A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Upon further questioning you discover the following subjective information regarding the chief complaint.

History of Present Illness


"about 2-3 months"






Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well rested. "No energy to do anything I normally can do"

Aggravating factors


Relieving factors

None identified




Denies pain; missed 1 day of work 2 weeks ago because "couldn't get out of bed"

Review of Systems (ROS)


Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months ago.


No visual changes or diploplia


Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea.


Denies lymph node tenderness or swelling


Denies cough, SOB, DOE or wheezing


Denies chest pain


Denies N/V/D. + Constipation


Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.


No changes in skin, hair or nails


Reports worsening of depressive symptoms but thinks it is because she is so "unproductive" lately and tired all of the time. -Suicidal or homicidal thoughts. Sleeping 8-9hrs per night (no changes), but not feeling rested.


Generalized weakness and intermittent muscles cramping in calves



Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU.


HTN, Depression, Postmenopausal status




Iodine dyes


Married; Works full time as office manager of an internal medicine office; 2 kids (grown)


Denies cigarettes or drug use. +Occasional glass of wine (1-2 per month).


Maternal GM & GF deceased with CHF, T2DM and HTN;

Mother alive (age 82) +HTN, +Hyperlipidemia, +T2DM;

Father alive (age 84) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p CABG 2 years ago). Also had +CVA at time of CABG (work-up revealed +DVT and +PFO; remains anticoagulated);

Oldest child (26) with seasonal allergies

Youngest child (24) with Bipolar depression and ADHD, and anxiety

Physical exam reveals the following:

Physical Exam


Middle aged Caucasian female alert, oriented and cooperative


Temp-98.2, P-74, R-16, BP 146/95, Height: 5'7", Weight: 180 pounds


Normocephalic, atraumatic




Tympanic membranes gray and intact with light reflex noted.


Nares patent. Nasal turbinates without swelling. Nasal drainage is clear.


Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities.


Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.


Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. No pedal edema


Soft, non-tender. BS active


Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration


Mood pleasant and appropriate.


Strength full throughout


DTRs 2+ at biceps, 1+ at knees and ankles

  • Briefly and concisely summarize the H&P findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information.
  • Provide a differential diagnosis (minimum of 3) which might explain the patient's chief complaint along with a brief statement of pathophysiology for each.
  • Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis. Rank the differential in order of most likely to least likely.
  • Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBM.

dq 2

Week 6: Discussion Part Two

77 unread replies.2121 replies.

Now, assume that you sent your patient for labs and she returns the following day, as instructed, to review the results.

CBC with differential


8.6 x10E3/uL


4.44 x 10E6/uL


14.0 g/dL






31.5 pg


34.0 g/dL




241 x 10E3/uL

Neutrophils %


Lymphocytes %


Monocytes %


Eosinophils %


Basophils %


Absolute Neutrophils

5.7 x 10E3/uL

Absolute Lymphocytes

1.9 x 10E3/uL

Absolute Monocytes

0.7 x 10E3/uL

Eosinophils Absolute

0.3 x 10E3/uL

Basophile Absolute

0.0 x 10E3/uL

Immature Grans %


Absolute Immature Grans

0.0 x 10E3/uL

TSH with Reflex to FT4


6.770 uIU/mL


0.62 ng/dL

PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago)

  • What is your primary diagnosis for this patient as the cause for the CC of fatigue? (support your decision for your diagnosis with pertinent positives and negatives from the case)
  • Identify the corresponding ICD-10 code.
  • Provide a treatment plan for this patient's primary diagnosis which includes:
  • Medication*
  • Any additional testing necessary for this particular diagnosis*
  • Patient education*
  • Referral and follow-up to the treatment plan
  • Provide an active problem list for this patient based on the information given in the case.
  • Are there any changes that you would make to the patient's overall plan at this time? Must provide an evidence-based medicine (EBM) argument to support any treatments or testing decisions.
  • Provide an appropriate follow-up plan (include any additional testing that you feel is necessary and include an EBM argument).

*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an EBM argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.

NR511 week 6 -Discussion 1 and 2 - April 2018
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Dated: 11th Jul'18 09:12 AM
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Replacement     Levothyroxine       Hypothyroidism   Adults Indian     Endocrinology       404-409   4103/ijem IJEM_502_16U     of       Services   The National     Diabetes       Kidney   Hashimoto's Disease:     https://www       S   of Health     Services,       Health,   Medline Plus:     from       Reply   to CommentCollapse     SommerApr       4   5:12pmHi Kelly,     I       lot   your post     said       consider   the patient     endocrinologist,       actual   of when     so       interested   when we     to       of   Endocrinologists and     Thyroid       should   referred to     if       children   infants2) when     difficult       maintain   TSH +     levels3)       pregnant   who are     become       have   disease5) those     any       their   including a     nodule6)       has   or pituitary     thyroid       causes   hypothyroidism I     my       we   to manage     patient       without   the patient     specialist       very   in a     hypothyroidism,       refer   patient to     Thanks,RebeccaReferencesGarber,       Cobin,   H ,     ,       ,   I ,     I       ,   ATA/AACE Guidelines:     guidelines       adults:   by the     of       the   Thyroid Association     18(6),       https://www   com/files/final-file-hypo-guidelines pdf     an       Reply   to CommentCollapse     BushL       2018   5 at     What       As   developed my     I       recommendations   what tests     to       of   if additional     warranted,       would   information for     or       change   treatment plan     been       I   had with     as       plans,   when our     does       clinical   guidelines It     at       situation,   using clinical     achieve       evaluating   function tests,     picture       considered,   as overall     of       pregnancy,   exposure, or     (Gregory       overall   and organ     considered,       and   relationship to     obesity,       systems,   more in-depth     be       (2014)   out that     for       antibodies   provide additional     test       change   management of     is       results   the TSH     serum       levels   testing is     patients       and   usually done     endocrinologist       damage   risk for     (Dunn       In   case of     with       thyroid   nodules, would     or       needed   justified since     not       diagnoses   2016)? Does     the       the   in such     often       on   discuss whether     additional       decision   on “Will     change       On   occasions, testing     done       family’s   for information     there       for   guidelines (Gregory     clinical       experience   familiarity with     to       ReferencesDunn,   & Turner,     Hypothyroidism       for   Health [online]     https://doi       2015   002Gregory Curl,     Hypothyroidism       Reviews,   40-46 Retrieved     b       idm   org/eds/pdfviewer/pdfviewer?vid=6&sid=e73f7549-a88a-4c77-bb3d-802c68602b1d%40sessionmgr120Hollier, A     guidelines       (2nd   Scott, LA:     Education       Reply   CommentCollapse SubdiscussionDana     8,       at   if you     rx       weight,   will you     recommended       practice   What is     code       You   that you     antibody       but   not have     Can       hashimotos   this point?     a       and   being treated     at       thyroid   may improve     Will       discuss   plans at     Do       document   in your     symptoms       to   that might     to       DanaEdited   Dana Buechner-Wiegand     8       Reply   CommentCollapse SubdiscussionKaly     8,       at   and Class     will       dosing   and potential     In       habits,   is most     on       or   hours after     Resource,2018)       coffee   grapefruit can     or       of   absorption (Clinical     and       chromium,   salts, and     bind       less   bioavailability of     (Clinical       suppressants   as H2-     pump       lower   pH levels     result       (Clinical   Is should     to       regular   and consistency     for       Since   therapy is     established       the   will provide     results       consistency   time is     in       specific   related to     evening       not   discovered as     Resource,2018)       also   instructed that     may       or   based on     Therefore,       need   know ahead     that       and   testing may     be       patient   adequately managed     changes       visit   weeks after     has       serum   and Free     indicates       prescription   (Reed, 2016)     interval,       monitor   emotional and     to       as   weakness, and     should       time   testing will     at       ensure   health improvement     time,       is   Without signs     or       needing   intervention, or     additional       testing   not change     of       overall   for normal     Free       De   & Rose,     additional       suspected,   as Hashimoto’s     for       such   thyroperoxidase or     then       to   cost for     of       should   informed of     and       decline   testing at     The       be   that results     testing       the   treatment plan     ,       ,   Rose, N     thyroiditis:       criteria   Reviews, 13(4-5),     10       01   Resource (2018)     The       and   Pharmacist’s Letter/Prescriber’s     from       aspx?cs=MOBILEORDER,&s=PRL&DocumentFileID=0&DetailID=310420&SegmentID=0   L (2012)     A       Clinical   in Primary     234-235)       Practice   Associates, Inc     to       BushL   BushApr 3,     3       old   female has     diagnosis       E03   diagnosis is     an       (6   uIU/ml) with     hypothyroidism       with   TSH levels     levels       normal   this case)     low       Curl,   The risk     this       being   female, and     evidence       complaints,   exam, and     are:Pertinent       female,   56, gradual     constant       energy   with exertion,     BMI       tired   unrested after     normal       intolerance,   depression (PHQ-9     6       General   and muscle     calves       coarse   hair, small     decreased       BLE   6 770     0       negatives:   Oriented, pleasant,     No       pain,   chills, or     Eyes       no   thyroid midline     heart       HR   and no     lungs       unlabored   soft, non-tender,     symptoms,       pitting,   discoloration Full     all       at   WBC 8     RBC       10E6/uL,   14 g/dL,     2%,       CBC-negative   anemia) Treatment     medications       fumarate/hydrochlorothiazide   5 mg     2018)Sig:       once   # 30     The       guidelines   managing hypertension     al       this   hypertension (HTN)     as       which   SBP ≥140     ≥90       target   pressure (BP)     mm       the   of cardiovascular     are       with   syndrome, diabetes,     With       fatigue,   physical activity,     and       multiple   factors (T2DM,     DVT),       be   and reassessed     weeks       (Levothyroxine,   one tablet     on       #   (fifty) (Enough     given       to   a steady     allow       (No   are given     levels       and   needs evaluated)     practice       the   treatment for     formulations       consistent   achieve consistent     (Jonklaas       2014)   dosing of     based       weight   than actual     taking       (reduced   needs in     r/t       mass),   of TSH     status,       absorption,   interactions, etiology     and       Height   wt 180     BMI       body   (IBW) approx