Mrs. M is a 52-year-old female with a history of depression for 10+ years. She was taking Prozac 20 mg per day for her depression but was switched to Cymbalta 60 mg a year ago due to chronic back pain. She reports that the past 3 months her depression has been worsening. She feels hopeless and helpless. She also feels guilty because she has been less helpful to her friends and family members. She has increased fatigue and decreased energy. She has not been going places or finding enjoyment in activities. Her back pain has increased. She finds it difficult to do the dishes because of the pain and fatigue. She also reports panic attacks, which are new for her. During the panic attacks, she is short of breath, has palpitations, shakiness and sweats. They last 5-15 minutes, and then resolve, leaving her exhausted. She reports losing weight. Her weight at her last visit was 129 pounds at 5’3″, and it 119 pounds today. She reports decreased appetite, although she feels she is still eating just as much, “but I might not be. I can’t tell.” Her temp is 99.2, pulse 94, resps 22, BP 128/82. She appears anxious and speaks rapidly. You note a fine tremor. Her eyes, nose, and throat are normal. Mrs. M is a widow; her husband died 3 years ago. She has 2 adult daughters that live nearby. She owns her own home. She was a stay at home mom and has not worked since her youngest daughter was born. She used to babysit her grandbaby in the mornings, “but I get too nervous to do that anymore. She had an appendectomy in 1992, and a cholecystectomy in 2000. She drinks 3 cups of coffee per day and a 24 ounce Mountain Dew. She consumes 1-2 glasses of wine nightly before bedtime. She does take Tylenol and Advil as needed for her back pain, and muscle relaxer prn. She denies diarrhea or constipation, although she has intermittent indigestion, for which she takes OTC Zantac 2-3 times a week. She denies nausea or vomiting. She does not exercise regularly. She smokes ½ ppd. She denies chest pain except during her panic attacks. She reports feeling dizzy during panic attacks. She is irritable pretty often and has been snapping at her children and grandchildren lately. She has never been hospitalized for psychiatric reasons, or reasons other than her two surgeries and childbirth.
- The information for you to present from is given below, in no particular order. You need to organize it, put together the differential, and present it. If further information is needed while the patient is in the clinic, you need to tell the preceptor what further questions or examination you feel the patient needs and why.
- Be sure to include any diagnostic tests you would order for this patient. Any diagnostic tests you want to order should be clearly connected to one of your differential diagnoses. If you DO NOT order diagnostic tests you must give a rationale for that as well. Your rationale needs to have a citation.
- Subjective data: to include pertinent other history factors, such as recent hospitalizations, pertinent immunization history. You will be adding diagnostic testing and rationale, so in order to keep your recording under 4 minutes, you will need to omit information that is not relevant.
- Objective data: Physical exam findings
- Differential diagnoses (minimum of 3 for this presentation; you will not need that many for every patient in the clinical setting)
- Reasons for choosing those, and which one you believe most likely with rationale
- Questions for preceptor/faculty about the case or the diagnosis
- Plan: what will be what diagnostic tests you recommend, if any, and why, with some mention of cost vs. benefit
- Further learning you feel you need related to this case
- Reference(s) used in developing your differential and the diagnostic test recommendations
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