11 May WHAT IS YOUR DIFFERENTIAL DIAGNOSIS LIST FOR THIS VISIT THUS FAR WITH RATIONALE?
PMHx: Julia’s mother reports her overall health as good.
Childhood/previous illnesses: None
Chronic illnesses: None
Surgeries: None
Hospitalizations: None
Immunizations: Childhood immunizations UTD. Receives the flu shot every year
Allergies: Seasonal
Blood transfusions: None
Denies ETOH, tobacco, illicit drugs
Sleep: Sleeps 5 to 6 hours a night. States “I can’t fall asleep.”
Current medications: None LMP 1 week ago
Social Hx: Good student. Lives with parents and older sister and younger brother
Family Hx: Mother no health problems, father bipolar and well controlled. Siblings in good health. MGM and PGM deceased from breast CA. MGF deceased: lung CA. PGM alive, 85, overall health good. Has Type 2 diabetes.
Discussion Questions Part One:
What further questions do you have for Julia at this visit?
What is your differential diagnosis list for this visit thus far with rationale?
Based on your differential diagnoses list, identify what body systems you’d examine along with pertinent positive/negatives in each system and any diagnostic tests you would like to perform?
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