Reference no: EM133224755

Question: 72-year-old Caucasian widowed woman who lives independently in the community, no significant past medical history. She presents as a new patient to your office with complaint of fatigue and anorexia. Rita's daughter, who accompanies her today, fears that Rita may be depressed.

The patient says the fatigue began a month or two ago and has been getting steadily worse. She tells you she can't complete her usual activities. She has started to rely on her daughter to do her grocery shopping and housework because she becomes exhausted doing these activities and is a little short of breath.

Physical Exam Findings

Height: 5'4"

Weight: 120 lbs.

BP: 122/64

HR: 100 regular with no rubs, murmurs or gallops.

Lung sounds clear, full, and equal bilaterally.

Abdomen: soft, non-tender, no masses or organomegaly.

Questions About the Patient

Answer these questions:

Subjective: What subjective data do you need to gather from this patient?

Objective: What objective data would you gather for this patient? Explain your expected findings or state specifically what you are looking for.

Assessment:

List three differential diagnoses with cited rationale.

List at least two medical diagnoses with cited rationale, including the ICD-10 codes based on the following lab values:

WBC 4.2; Hgb 9; Hct 25; RBC 3; MCV 110; TSH 3.

Plan: For each diagnosis, write a care plan. Each diagnosis should have all five components of a plan.

Diagnostic testing

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic

Education, including health promotion, maintenance, and psychosocial needs

Referrals

Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit