ASSIGNMENT: Provide evidence from the literature to support diagnostic tests tha

ASSIGNMENT: Provide evidence from the literature to support diagnostic tests that would be appropriate USING THE case study. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
SAMPLES UPLOAEDED.
CASE STUDEY
Patient Initials: _____TJ__ Age: ___28____ Gender: ____F___
SUBJECTIVE DATA:
Chief Complaint (CC): Patient presents with need for physical exam for a new job.
History of Present Illness (HPI): TJ, a 28-year-old African American female, presents for a routine physical exam for the health insurance at a new job. All allergies, medications, medical, surgical social, and family history reviewed today.
Medications:
Metformin 850mg PO BID for diabetes,
Flovent inhaler 2 puffs BID for asthma,
Albuterol PRN for shortness of breath,
Drospirenone/ethinyl estradiol 1 pill daily for birth control and PICOS,
Advil PRN for menstrual cramps.
Allergies:
Penicillin (rash/hives).
Cats (triggers asthma attack),
Dust (asthma attack trigger),
Denies food allergy.
Denies latex allergy.
Past Medical History (PMH):
Asthma
DM II
GERD
Acne
PCOS
Denies resent hospitalization.
Past Surgical History (PSH):
Denies previous surgeries
Sexual/Reproductive History:
Heterosexual, denies ever being pregnant.
Denies ever being pregnant,
LMP two weeks ago, menarche age 11
Personal/Social History:
College grad with B.A. in accounting,
Denies currently smoking, stopped smoking at 21,
Denies illicit drug use,
Occasional alcohol, drinks with friends.
Marijuana use, last at 21 years of age.
Lives at home with mother and sister.
Support system: family.
Baptist by religious affiliation.
Health Maintenance:
Gets healthcare insurance through her job. Last Healthcare visit was four months ago. Controlling type 2 diabetes with diet exercise and Metformin. Monitors blood glucose at home. Gets regular exercises; walks for 30 – 40 minutes 4 – 5 times weekly, swims once a week.
Immunization History:
Up to date on vaccines.
Current Flu vaccine pending.
Significant Family History:
Mother high cholesterol, hypertension
Father high cholesterol, hypertension.
Paternal grandfather hypertension, diabetes, colon cancer.
Paternal grandmother hypertension.
Maternal grandfather hypertension, high cholesterol, heart attack.
Maternal grandmother hypertension, high cholesterol.
Sister asthma.
Brother overweight.
Review of Systems:
General: No fevers, no chills, no night sweats, no fatigue, no unexpected weight loss.
HEENT: Head: no trauma, no headaches
Eyes: No change in vision, no eye pain, no blurry vision.
ENMT: No ear pain or drainage, no nasal congestion or runny nose, no sore throat or difficulty swallowing.
Respiratory: No shortness of breath, no cough, no wheezing.
Cardiovascular/Peripheral Vascular: No chest pain, no pressure, no palpitations, no dizziness, no loss of consciousness.
Gastrointestinal: No change in bowel habits, no nausea, no vomiting, no diarrhea, no constipation, no melena, no anorexia.
Genitourinary: No hematuria, no nocturia, no discharge, no change in urinary frequency, no urinary retention
Musculoskeletal: No back pain, no neck pain, no joint pain, no muscle pain, no swelling, no change in range of motion.
Neurological: No headache, no numbness, no tingling, no limb weakness, alert and oriented x 3.
Psychiatric: No anxiety, no depression, no suicide ideation.
Skin/hair/nails: Facial acne, no abrasions, no lesions.
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP 128/82, MAP 97.3, HR 78, RR 15, O2Sat 99%, Temp 37.2oC, Pain 0
General: TJ is calm and alert, maintains good eye contact, well nourished, well formed, appropriate speech, and well groomed.
HEENT:
Head and Neck inspection: Scattered pustules on face and facial hair on upper lip. Head is normocephalic, atraumatic, normal scalp hair distribution, acanthosis nigricans noted on neck.
Eyebrow and orbital area: Right and Left eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema.
No masses noted on head palpation.
No frontal sinus tenderness, no maxillary sinus tenderness.
Jaw noted with no clicks, and full ROM.
No axillary and supraclavicular lymphadenopathy.
Thyroid smooth without nodules, no goiter.
Eyes: Upper and lower eyelids and conjunctiva observed with pink conjunctiva, no lesions, white sclera.
Right and left pupils equal, round and reactive to light.
Eye movements have normal convergence, EOMS intact bilaterally, no nystagmus.
Peripheral vision intact in both eyes, all fields.
Interior eyes noted with mild retinopathic changes to light, left fundus with sharp disc margins, no hemorrhages.
Visual acuity 20/20 with corrective lenses in both eyes.
Nose: Left and right nasal cavities noted with moist and pink nasal mucosa, and midline septum.
Ear: Left and right ear cavities noted with TM intact and pearly gray, positive light reflex.
Mouth and Throat: Oral mucosa moist without ulcerations or lesions, uvula midline, gag reflex intact.
Chest/Lungs: Oxygen saturation 99%.
Lung capacity: FVC 3.91 L, FEV1/FVC ration 80.56%
Anterior and posterior chest wall symmetric, no deformities or lesions.
Thoracic expansion symmetric.
Normal fremitus in all chest wall areas.
Anterior and posterior chest wall percussion noted with resonance in right/left upper chest, right/left middle chest, and right/left lower chest.
Breath sounds in anterior and posterior chest walls noted with no adventitious sounds throughout.
Anterior and posterior lungs auscultation for bronchoscopy shows muffled voice sounds throughout the lungs
Heart/Peripheral Vascular: Pulses of the head and neck 2+, no thrill, bilaterally.
PMI palpated at the mid clavicular line, 5th intercostal space, no heaves or lifts.
Bilateral upper extremities: right/left radial and brachial pulses 2+.
Bilateral lower extremities: right/left femoral pulse 2+, right/left popliteal pulses 2+, right/left tibial pulses 2+, right/left dorsalis pedis pulses 2+.
Right and left carotid artery auscultation: no bruit.
Heart sounds auscultation with bell:
Erb’s point, aortic area, pulmonic area, tricuspid area, mitral area – no S3, S4.
Heart sounds auscultation with diaphragm:
Erb’s point, aortic area, pulmonic area, tricuspid area, mitral area – RRR, S1, S2, no murmur.
Arteries of the body noted with no bruit bilaterally.
Capillary refill < 3 sec. No edema noted. Abdomen: Abdomen protuberant, symmetric, no visible masses or lesions, coarse hair from pubis to umbilicus. Normoactive bowel sounds in all quadrants. Aortic artery - no bruit. CVA tenderness - none reported in right/left flanks. Spleen percussion - no dullness, Liver span percussion - 7cm MCL. Abdomen percussion noted - tympanic in all quadrants. Light abdomen palpation - soft, no tenderness no masses in all quadrants. Deep abdomen palpation - no masses, guarding or rebound in all quadrants. Organs palpation: Liver - palpable 1 cm below right costal margin, Spleen - not palpable, Bilateral kidneys - not palpable, no masses. Genital/Rectal: Deferred Musculoskeletal: Neck without swelling, masses, or deformity. Bilateral shoulders without swelling, masses or deformity, Bilateral arms without swelling, masses, or deformity. Bilateral elbows without swelling, masses, or deformity. Bilateral wrists and hands without swelling, masses, or deformity. Fingernails - no ridges or abnormalities in nails, pink nailbeds. Hips without swelling, masses or deformity. Lower extremities - no swelling, masses, deformities, or discoloration in bilateral legs, knees, ankles and feet. Toenails - no ridges or abnormalities in nails, pink nailbeds. Full ROM in all extremities, spine, and hips. 5/5 strength in all extremities, neck and hip. Neurological: Graphesthesia: Identified the number eight drawn on right hand, identified the letter "A" drawn on the left hand. Sensation in feet with monofilament - no decreased sensation in right and left feet. Light touch sensation in bilateral upper and lower extremities intact. Dull pain sensation in bilateral upper and lower extremities intact. Position sense intact in toes and fingers. Stereognosis: identified coin in bilateral hands within 5 seconds, identified paper clips in bilateral hands within 5 seconds, identified key in bilateral hands within 5 Seconds. Tendon reflexes 2+ in all extremities. Right finger to nose smooth and accurate. Left finger to lose smooth and accurate. Heel - to shin coordination smooth and accurate in bilateral feet. Rapid alternating hand movements smooth Skin, Hair & Nails: Warm and dry. No ridges or abnormalities in nails, pink nail bed noted in toe nails and finger nails. Normal scalp hair distribution. Acanthosis nigricans noted on neck. Acne on cheeks and jaw. Mole on posterior right shoulder.