14 May PATIENT ASSESMENT
Patient Assesment
All questions must be answered and referenced as needed.
Instructions
This assessment consists of four (4) case studies all must be completed. You are required to
1. Answer any specific questions asked in the case study
2. Provide a probable diagnosis with justification and provide at least 1 other differential diagnosis
Case One
A 49yo woman presents to you for a health check. She has been in a stressful job for the past 4 years, and is on a one month break before taking up a new job, which she hopes will be less pressured. She doesnt feel she has any health issues or problems and wants to use this time to make some positive health changes. Height 170cm, weight 87kg, BP 125/85, pulse 71, waist 85cm During the consultation with you, you elicit the following information:
? Breakfast consists of toast and jam or vegemite and white coffee with 2 sugars
? Morning tea is an apple or crackers and cheese and another white coffee with 2 sugars
? Lunch is pasta or sushi rolls or ham and cheese toasted sandwich and a 600mL bottle of soft drink
? Afternoon tea is white tea with 2 sugars and biscuits
? Dinner is cheese on toast, tinned soup, fruit and flavoured yoghurt
? She will often have 2 glasses of wine with dinner as she felt her old job was high pressure and she had earned a drink or two to relax and unwind she admits they may not be ‘standard glasses of wine
? She often gets palpitations in the afternoon, and occasionally feels short of breath when she has to run for a bus
? She does feel tired most of the time, and admits she has put on weight in the last couple of years, especially around the tummy
? Sometimes her tummy feels bloated and she gets a pain in her right side she describes it as ‘below my right breast, but behind my ribs.
? Sometimes at night she is woken be a sharp pain that starts in the same area, but goes through to her right shoulder blade
? She doesnt sleep well, as she often has to get up during the night to urinate usually once, sometimes more. She comments that during the day she seemed to urinate much more frequently than her previous colleagues
1. What issues should you consider in relation to a patient who feels they dont have ‘any health issues or problems?
2. What physical examination could you undertake in clinic that would provide you with additional information that might clarify this case?
3.Provide a probable diagnosis with justification and at least 1 other differential diagnosis
Case Two
A 35yo male presents to you in clinic. His presenting symptoms include a hacking cough, sometimes with mucus, shortness of breath, sometimes wheezing. He has had four (4) respiratory tract infections in the past 14 months. He works in a printing and copying business and is currently renovating a house with his partner. The dust from work and renovating seems to aggravate the cough. He tries to remember a good dust mask at while renovating. His health history includes childhood asthma, which he grew out of in his early teens he has not used any medication for this since he was (he thinks) about 14 he had ‘a puffer. He did smoke in his late teens and early twenties, but hasnt smoked since about age 25. His father (now aged 65) had a stroke at age 51 and is being treated for high blood pressure and high cholesterol. His father has never smoked or drank alcohol. His mother (age 62) has been a life long smoker, and despite a recent diagnosis of emphysema, continues to smoke about 5 cigarettes a day she hopes to quit soon. You notice that he scratches the inside of his elbows during the consultation and ask if there is a problem. He says he has ‘eczema and it also appears behind his knees, behind his ears and at his hairline. It gets worse with heat or in the spring and sometime he think what he eats might ‘set it off, but hasnt really paid attention to it. His doctor gave him some cream, but he never remembers to use it until it is too late. Specific questions relating to the case study
1.What physical examination could you undertake in clinic to provide additional information that might clarify this case? (dot points are allowed you must give a reason for why you undertake each physical examination to show its relevance to this case)
2. Is there any other information you would like to clarify this case or questions you could ask? (dot points are allowed- briefly explain why the question is relevant to this case)
3.Provide a probable diagnosis with justification and at least 1 other differential diagnosis
Case Three
A 30 yo female patient presents with symptoms including tiredness, foggy headedness, heavy periods and frequent colds. She is 170cm tall and weighs 59kg. Her diet is good and includes red meat 1/7, fish 3/7, tofu / legumes 2/7, fruit 2/day and a good range of vegetables, but she does not like potatoes. She does eat white rice (basmati) 3 4 times a week. Breakfast is Bircher muesli. Lunch is a mountain bread (whole grain) wrap with egg or tuna and carrots, tomato, beetroot and lettuce 4 days a week; on Fridays they have pizza or fish and chips at work. She does get sugar cravings at about 3.30, but tries to eat fruit Fridays she will give in and have sweet biscuits for tafternoon tea. She does not drink alcohol or soft drinks. She has 3 white coffees a day (no sugar) and one green tea after dinner. She cant understand why she feels so rotten, when she is doing all the right things.
The following results of a blood test results are subsequently received from her general practitioner:
Result
Reference range
Hb
103g/L
115 165
RCC
5.6 x 1012
3.9-5.8
Hct
0.34
0.34-0.47
MCV
64fL
79-99
MCH
20pg
27-34
MCHC
315g/L
320-360
RDW
16.10%
01/10/17
Plat
273 x109 /L
150-400
WBC
Neut
7.6 x109 /L
4 11
Lymp
3.3 x109 /L
01/04/15
Mono
0.3 x109 /L
0.2-1
Eos
0.3 x109 /L
<0.7
Baso
0.1 x109 /L
<0.2
Other
ESR
100
(0-20)
Ferritin
23mcg/L
15-200
The Laboratory included the following comments: ? Red Cells: Anisocytosis +, Microcytosis ++ Hypochromia ++, Eliptocytosis ++, occasional fragmented cells? White cells: normal ? Platelets: normal
Specific questions relating to the case study
1.What physical examination could you undertake in clinic that would provide you with additional information that might clarify this case? (dot points are allowed you must give a reason for why you undertake each physical examination to show its relevance to this case)
2. Is there any other information you would like to clarify this case? (dot points are allowed)
3. What complementary tests could be ordered for this patient and why? You should justify the tests you think are necessary by explaining what information the test would give and how this would contribute to your diagnosis or differential diagnosis (dot points are allowed you must give a reason for why you undertake each physical examination to show its relevance to this case)
4.Provide a probable diagnosis with justification and at least 1 other differential diagnosis
Case Four
A 34yo woman presents at clinic seeking preconception advice. She is 175cm tall and weighs 62kg. She and her partner are trying to start a family and have been having unprotected intercourse for 10 months, without success. Her periods are regular (every 27-28 days), are not heavy and there is no clotting or cramping. Her partner is having a semen analysis to determine if there are any problems from that respect, although those results are not yet available. She practices yoga 4 mornings a week, walks at weekends for 1 hour and her diet is excellent. Neither she or her partner drink alcohol or coffee. Her energy levels are good, but she admits to being stressed about not conceiving. Timing of intercourse is good for conception.
Her general practitioner has requested a set of tests, a copy of which she has brought to her appointment with you.
Her FBC is all well within normal limits, although her Ferritin is 23mcg/L (15-200) and the Laboratory has noted ‘Serum Ferritin levels between 15-30mcg/L may reflect depleted iron stores and iron therapy may be indicated. Her GP has started her on iron supplements.
Her thyroid function has come back with the following results:
Result
Reference range
Free T3 (FT3)
5.94pmol/L
2.5 6.0
Free thyroxine (FT4)
18 pmol/L
01/08/22
TSH
6.28mIU/L
0.30-4.00
Specific questions relating to the case study
1.What physical examination could you undertake in clinic that would provide you with additional information that might clarify this case? (dots points are allowed you must give a reason for why you undertake each physical examination to show its relevance to this case)
2. Is there any other information you would like to clarify this case? (dots points are allowed briefly explain why the information is relevant to this case)
3. What complementary tests could be ordered for this patient and why? You should justify the tests you think are necessary by explaining what information the test would give and how this would contribute to your diagnosis or differential diagnosis (dots points are allowed you must give a reason for why you undertake each physical examination to show its relevance to this case)
4. Provide a probable diagnosis with justification and at least 1 other differential diagnosis
Instructions Summary: In 500 words, for each of the four (4) case studies, provide the answers to the case related questions and give a probable diagnosis with justification with at least 1 other differential diagnosis.
Referencing: Your assignment must include a properly formatted bibliography, listing all resources used in the interpretation and recommendations of the four cases. In text referencing is not required for this assessment
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