Endocrine Case Study

Endocrine Case Study

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A 38-year-old Caucasian female, well known to your practice, presents with the new complaints of losing weight despite a strong appetite and being able to eat a great deal. Her lifelong constipation has resolved. She has feelings of breathlessness, and anxiety. She also reports recent onset of difficulty sleeping, shakiness, and increased irritability. She also reports “sweating” and “decreased libido.” She is a gravida 2, para 2, and works full-time. Both her young children are in school. She is happily married. She denies chest pain, orthopnea, paroxysmal dyspnea, and edema.

CC: “I just don’t feel like myself. I’m shaky and anxious. I can’t sleep and I am sweaty all the time. Could I be having early menopause?”

Physical Exam:

Vital signs: Blood pressure is 110/64. Heart rate is 104 beats/minute. Respiratory rate is 24 breaths/minute. Afebrile. Height is 5’7”. Weight is 110 pounds, which is down from 119 pounds on her last visit 8 months ago for her yearly GYN exam.

Anxious, thin patient, with thinning, dry hair. Thyroid exam reveals a bruit over the thyroid. She also has increased pulse pressure and warm moist skin.

Students are to respond to all of the following questions:

What additional subjective data (list 5) would you collect? (
15 points)

What additional objective data (excluding laboratory or diagnostic studies, list 5) would you collect? (
15 points)

List and
prioritize differential diagnoses (list 4) you would consider. For each differential diagnosis proposed, list specific information from the case study or from your suggested data that supports the diagnosis. (
20 points: 3 points for each appropriate diagnosis, 2 points for each RATIONALE of diagnosis)

What laboratory or diagnostic studies should be considered to assist with or confirm the diagnosis, and what would be the EXPECTED FINDINGS of these studies? (
15 points)

Outline your treatment plan:

· Recommended prescription therapy: (
10 points)

· 5 points for appropriate prescriptive therapy (including dosing)

· 5 points for RATIONALE of therapy

· Recommended non-prescription (OTC, complementary) therapy (list 3): (
10 points)

· 5 points for each non-prescription therapy, including dosing, if applicable

· 5 points for each RATIONALE of therapy

Propose referrals to other health care professionals and indicate the purpose (goal) of the referral. (
3 points)

Describe patient/family teaching topics (list 3) that would be appropriate for this case. (
3 points: 1 point for each DISTINCT and SPECIFIC topic)

Identify any cultural, socioeconomic, religious, or psychosocial issues (list 3) that you have considered in your treatment plan. (
3 points: 1 point for each DISTINCT and SPECIFIC issue)

Case-specific questions. (
3 points)

· Which Healthy People 2030 objectives are relevant to this case?

· What are standard screening recommendations for thyroid function?

Identify preventative care that would be appropriate for this patient (immunizations, screenings, etc.). (
2 points)

Which Centers for Medicare & Medicaid Services Evaluation & Management (CMS

E&M) code would you assign this visit? Provide a rationale for your answer. (
1 point)

Total possible points: 100

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