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

Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving actual patient problems in the same manner as they occur in practice. The purpose of this activity is to develop students’ clinical reasoning skills using a case-based learning exercise. Through participation in an online discussion forum, students identify learning issues in a self-directed manner which facilitates learning for the entire group.
Briefly and concisely summarize the history and physical (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 evidence.
Case Study
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
Application of Course Knowledge : A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND
Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND
A brief statement of pathophysiology is included for each diagnosis; AND
Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND
The differential is ranked in order from most likely to least likely; AND
Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND
Testing decisions are well supported with EBM arguments that are in-line with the clinical scenario and appropriate for the primary care setting
Support from Evidence-Based Practice (EBP): Discussion post is supported with appropriate, scholarly sources; AND
Sources are published within the last 5 years (unless it is the most current CPG); AND
Reference list is provided and in-text citations match; AND
All testing decisions are fully supported with an appropriate EBM argument
Interactive Dialogue: Student provides a substantive* response to at least one topic-related post of a peer; AND
Evidence from appropriate scholarly sources are included; AND
Reference list is provided and in-text citations match; AND
Student responds to all direct faculty questions
Organization: Case study response is presented in a logical format, AND
Responses are in sequence with the numbered questions AND
The case study response is understandable and easy to follow AND
All responses are relevant to the case topic
Grammar, Syntax, Spelling & Punctuation: Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors*

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