Eliana Copeland Legal Question & Answer Guide (With Explanation)
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Original Question
Eliana Copeland (legal name: Elias Copeland), a 45-year-old African American femalewho was assigned male sex at birth, presents to your clinic as a new patient to establishcare. She has no physical complaints and is requesting medication refills as she has beenout for 2 days. She is new to the area and recently had her belongings stolen while stayingat a local shelter for homeless individuals. She states the following medications areworking well for her and reports no intolerable side effects or adverse reactions: Triumeq 1 tab PO QD Estradiol 2mg PO BID Spironolactone 50mg PO QD Quetiapine 50mg PO QHS Escitalopram 10mg PO QD Amlodipine 2.5mg PO QD Question 1:Based on the information provided, what are your workingdifferential diagnoses? Question 2:What history questions would you ask based on the information given? Case Study Part 2:Ms. Copeland further details her history. She has struggled with her identity since her youth, also disclosing a history of depression she contributes to her years living in foster care. However, 2 years ago she found comfort and clarity in a transgender support group in Seattle, WA. She states a concern for relapsing depression since she just moved to the area and does not have a support group yet.She began hormone therapy approximately 1 year ago and states she has been happiersince and would like to continue treatment; she eventually would like to undergo genderaffirmation surgery once her housing situation is stable. She denies alcohol or recreational drug use, except for occasional marijuana. She is a tobacco cigarette smoker of ΒΌ ppd x 20 years. She discloses being in an open relationship with a male partner and is currently working as a prostitute. Her last STI check was approx. 6 months ago, with no new abnormal results. Question 3:What screening tools would you use during today’s visit? Question 4:What focused physical exam will you complete today? Case Study Part 3:Objective Information: Vital Signs BP: 122/68 Pulse: 84 Temp: 97.2 F (oral) Respirations: 16 (unlabored) Height: 6ftWt: 164BMI: 22.2 Physical exam unremarkable PHQ9 total: 8, denies suicidal ideations or homicidal ideations GAD or MDQ also may be used Question 5: Based on the patient’s history and physical exam, what are your diagnoses today? Question 6:Would you refill her medications today? Question 7:What initial diagnostics will you order? Include your rationale for each order. Question 8:What healthcare maintenance items should be addressed? Question 9:What resources or patient education can / should you provide? Question 10:What is your follow-up plan? What would justify sending thispatient to a higher level of care?
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