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Case Study: Mrs. Lena Gonzales, a 68-year-old woman, presents to your office today with a complaint of feeling tired all the time and now, more recently, feeling weak. She states on this visit, “I can’t catch my breath sometimes.” She has been healthy except for high cholesterol, managed by Lipitor. Her husband died 9 months ago, and she has attributed her fatigue to dealing with his death but realizes that she is feeling worse and not better as time passes. She is a retired school teacher and has two daughters living nearby and 3 grandchildren she sometimes watches for her daughter. She has a close relationship with her daughters and their families. They have been a big source of support since her husband’s death. At this visit she appears tired. HPI – as stated in case above. Allergies: No known drug allergies. Medications: • Lipitor 10 mg po q H.S. • Ashwagandha 2100mg 2 caps daily – supplement for mood. PMH: As stated in case above. PSH: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago. VS: BP 106/70 Pulse 108 Resp 18 Temp 98.2 Ht 65 inches Wt 134 lbs BMI 22.3 Diagnostics/Assessments: Urine dipstick negative. The results of a recent colonoscopy show questionable neoplasm in the colon. PE: Conjunctiva pale, mucous membranes moist. No lymphadenopathy of neck or femoral area. Heart tachyarrhythmia with regular rate, soft midsystolic murmur. Chest (CTA), good air movement. Abdomen soft, bowel sounds × 4. ANSWER THESE QUESTIONS using up to date journal articles 1. What additional subjective data are you seeking? 2. What additional objective data will you be assessing for? 3. What additional medical history would you obtain from the patient? List at least three and put a rationale as to why? 4. What tests will you order? Describe at least four lab tests. put a rationale as to why? 5. What are the differential diagnoses that you are considering? Describe three and put a rationale as to why 6. What is your plan of care? Put a rationale as to why 7. List at least two diagnostic tests you will order to evaluate the cause of her condition and put a rationale as to why?
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