Case 1: A 42-year-old female complains of progressive weight gain of 20 pounds over the last year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. She claims her menses have been irregular x 1 year. She has an 18-year-old daughter, and has been attempting to have another child with her new partner. She has been unsuccessful.
1. What is the client’s chief complaint?
2. What questions would you ask the client?
o HPI (history of present illness)
o ROS (review of systems)
o Medical/Surgical/Psych History
o Family History
o Other
3. What physical examinations would you include?
4. What are pertinent positive physical assessment findings?
5. What are the pertinent negative physical assessment findings?
6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?
7. What is your primary diagnosis?
8. What is your treatment plan?
o Diagnostic procedures
o Labs
o Client education (including lifestyle modifications, if applicable)
o Pharmacotherapy (including complementary and alternative therapies)
o Health promotion (preventative care, anticipatory guidance)
o Follow-Up