Questions Develop Domain Question & Answer Guide (With Explanation)

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Questions to develop: DOMAIN: HISTORY 1a) Identify two (2) additional questions that were not asked in the case study and should have been? 1b) Explain your rationale for asking these two additional questions. 1c) Describe what the two (2) additional questions might reveal about the patient’s health. DOMAIN: PHYSICAL EXAM For each system examined in this case; 2a) Explain the reason the provider examined each system. 2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal. 2c) Describe the normal findings for each system. 2d) Identify the various diagnostic instruments you would need to use to examine this patient. DOMAIN: ASSESSMENT (Medical Diagnosis) Discuss the pathophysiology of the: 3a) Diagnosis and, 3b) Each Differential Diagnosis 3c) If it is a Wellness, type ‘Not Applicable’ DOMAIN: LABORATORY & DIAGNOSTIC TESTS Discuss the following: 4a) What labs should be ordered in the case? 4b) Discuss what lab results would be abnormal. 4c) Discuss what the abnormal lab values indicate. 4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis. Case study: Mr. Smith, is a 53-year-old male with a chief concern of swelling and pain in his left lower extremity. He has type 2 diabetes, obesity, hypertension, and hyperlipidemia. You note that he has not been to the office in the past six months, and it appears that he should be out of all of his medications. He replies, “It’s my left leg. The past four days it has been red, swollen, and painful—and it seems to be getting worse. It began several days ago, and the swelling seems to be getting worse. It hurts all the time; it doesn’t even get better when I rest it. It seems to get a little worse when I move around. It hurts to walk as soon as I try to stand on it. Social History: Does not drink alcohol, but does smoke 1.5 packs of cigarettes daily, he is unmarried, and lives in public housing with his three children and one grandchild. Review of Systems: No fever or chills, no chest pain, no shortness of breath, and no swelling of the right leg. Vital Signs: T 36.5 °C (97.8 °F), BP 140/90, HR 85, RR 12, O2 98% Cardiovascular and lung exam: Unremarkable Lower extremity exam: Mr. Smith’s entire left leg is swollen, warm and erythematous. The measurement of the circumference of the largest left calf section is 3.5 cm larger than his right calf at the same location. There is pitting edema. The leg is tender to the touch, especially along the distribution of the deep venous system. Dorsalis pedis and posterior tibialis pulses are palpable on both feet. Digital capillary refill time is two seconds. Deep tendon reflexes are present (2+). He has decreased sensation and is unable to determine the location of a monofilament test on either foot up to the ankle in a stocking distribution. You note a 2 cm ulceration on the plantar surface of Mr. Smith’s left foot. Most Likely Diagnoses Mr. Smith’s concern of swelling that is unilateral is an important finding to support the diagnosis of cellulitis, lymphedema, or deep vein thrombosis (DVT). In contrast, for venous insufficiency one would expect bilateral leg swelling. Peripheral artery disease (PAD) is not particularly associated with edema. Cellulitis and DVT are acute processes. Lymphedema, PAD, and venous insufficiency are less likely, given the acute nature of Mr. Smith’s symptoms. Since PAD, venous insufficiency, and lymphedema are not infectious processes, the lack of fever in Mr. Smith’s case keeps these diagnoses on the differential. In Mr. Smith’s case, the acute unilateral swelling, erythema, and warmth in a diabetic patient, make cellulitis (A) likely. The presence of a fever would support the diagnosis of an infectious process like cellulitis. But the fact that Mr. Smith does not have a fever doesn’t rule out a diagnosis of cellulitis as it is certainly possible to have localized cellulitis without fever. In Mr. Smith’s case, you feel that the acute nature of his symptoms—the unilateral swelling, and the presence of risk factors such as obesity, smoking, and diabetes—make DVT (B) a very likely diagnosis. Mr. Smith does not have a fever, but the inflammatory process due to a thrombus in his vein could explain his unilateral lower extremity edema. Lymphedema (C) can be present unilaterally, however this is usually a more chronically developing problem, making this diagnosis less likely. While venous insufficiency (G) could contribute to the development of a DVT, the acute and unilateral nature of Mr. Smith’s symptoms make you think a diagnosis of venous insufficiency alone is less likely. In Mr. Smith’s case, a diagnosis of PAD (E) seems unlikely given the lack of claudication and normal pulses on examination. Although PAD may not be the primary cause of Mr. Smith’s leg swelling and pain, it could potentially be contributing to it by increasing his risk for a foot ulcer. Mr. Smith’s history of smoking and diabetes increases the likelihood that he has PAD. Less Likely Diagnoses Muscle strain (D)—Although this can be a cause of swelling and pain, in a patient with intact mental status, a history of trauma should be present to consider this. Popliteal cyst (F)—This should be palpable behind the knee and rarely would cause the extensive swelling and pain seen in Mr. Smith. The following diagnostic tests is the best initial test with high predictive value for determining whether your patient has cellulitis or DVT? Venous Doppler of the lower extremity (E) should tell you with good sensitivity and specificity if a DVT is present. Mr. Smith’s ulcer is grade 2 (B). It is a deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. However, Mr. Smith’s wound does not demonstrate any signs of infection. Mr. Smith’s ulcer is more serious than grade 1 because it is not superficial (A) Mr. Smith’s ulcer is not as serious as grade 3 (C) because it does not involve abscess formation or osteomyelitis. It is not grade 4 (D) or 5 (E) because it does not involve gangrene.

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