L.J. is a 65-year-old Hispanic male who presents to the office with increased shortness of breath that has gotten worse over the last few months
December 29, 2017
Caucasian male child, appears stated age, Alert and cooperative, appears tired and distracted. Skin: color is pale pink, no cyanosis or pallor
December 29, 2017

Question
Setting: large urban city family practice clinic which employs physicians and nurse practitioners.

It is the end of a long day and you are ready to go home. Your last patient of the day is here with chief complaint of fatigue. You review the chart, you know this patient. You saw her last month. You wonder could fatigue be related her previous illness?

You enter the room and see Katie sitting in the chair. She looks up at you as you enter the room and responds quietly to your greeting. You ask Katie what brings her in today.

Katie states” I had pneumonia last month and I have not gotten my energy back. I feel like I got somewhat better, my cough is gone but I didn’t get my energy back. I just don’t feel like doing anything now. It’s hard to get up and get moving in the morning and I don’t sleep very well now. I keep waking up about 4 AM every day and I can’t get back to sleep. I try to go back to sleep but then I start thinking about all the things I need to do and being so tired and wanting to go back to sleep and then I can’t get back to sleep. I have not been to Curves since I had pneumonia”

PMH

Had chicken pox, measles and rubella as a child. Katie has a history of osteopenia, HTN and hyperlipidemia. Takes a multivitamin, Evista 60 mg daily and HCTZ 25 mg daily. No reports of past injuries. Previous surgeries include a tonsillectomy and cholecystectomy. Hospitalized for surgeries and childbirth. Has seasonal allergies to pollen and reports hayfever in the fall. Takes Allegra when needed. NKDA. No alcohol or tobacco use. Up to date on vaccines. Received the pneumonia vaccine last week.

Social

Married to John for 45 years, they live with married daughter and her family. Takes care of the kids and home as Mary and her husband work. Her husband and son both smoke but not in the house.

Family

Her parents died of old age. Siblings are well with same HTN problems she has.

Discussion part one:

What further questions do you have for Katie 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 would you order?

 

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