Case Study 2: HPI: Ms. Juggenmeir is a 71–year old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets.  She is also concerned that she may need to come off of one of her meds because her hair is thinning.  She had labs done and also was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin d daily as prescribed.

 Case Study 2:

HPI: Ms. Juggenmeir is a 71–year old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets.  She is also concerned that she may need to come off of one of her meds because her hair is thinning.  She had labs done and also was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin d daily as prescribed.

RESOURCE FOR THIS WEEK: Review Endocrine-related Evidence Based Practice Guidelines.

Ms. Juggenmeir is a 71 y/o female who is AAOX4.  She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain.

(All other Review of System and Physical Exam findings are negative other than stated.)

Vital Signs: BP 137/82, HR 89, RR 20, Temp 98.1

PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency

Allergies: I.V. Contrast, ACE Inhibitors

Medications:

Women’s One A Day-Multivitamin daily

Chlorthalidone 25mg daily

Fish Oil 1  tablet daily

Amlodipine 5mg p.o. daily

Losartan 100mg p.o. daily

Atorvastatin 40mg p.o. at bedtime daily

Aspirin 81mg p.o. daily

Ergocalciferol 50,000 units PO once a month

Social History: as stated in Case Study

ROS: as stated in Case study

Diagnostics/Assessments done:

 	
CXR- Last cxr showed no cardiopulmonary findings. WNL
 	
TSH/Free T4, T3- as noted below in lab results
 	
Basic Metabolic Panel and CBC as shown below
 	
Vitamin D Level- as noted below in lab results

TEST                                  RESULT                        REFERENCE RANGE

GLUCOSE                            85                                      65-99

SODIUM                              134                                    135-146

POTASSIUM                      4.2                                     3.5-5.3

CHLORIDE                        104                                      98-110

CARBON DIOXIDE         29                                       19-30

CALCIUM                          9.0                                       8.6- 10.3

BUN                                    20                                        7-25

CREATININE                   1.01                                     0.70-1.25

GLOMERULAR FILTRATION RATE (eGFR  76   >or=60 mL/min/1.73m2

 

TEST                                  RESULT                      REFERENCE RANGE

TSH                                     23                                 0.4-4.0

FREE T4                            0.05                             0.9-2.4 mcg/dl

T3                                        3.0                               2.0-4.4 ng/dl

Vitamin D 1,25 OH          14                                  36-144

 

TEST                                              RESULT    REFERENCE RANGE

WBC                                                   7.3               3.4- 10.8

RBC                                                    4.31              135-146

HEMOGLOBIN                               14                  13-17.2

HEMATOCRIT                                42%               36-50

MCV                                                   90                  80-100

MCHC                                                34                  32-36

PLATELET                                        272                150-400

 

 	
Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
 	
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
 	
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
 	
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned