Week 6 Case Study Discussion Part 2

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A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Upon further questioning, you discover the following subjective information regarding the chief complaint.

History of Present Illness
Review of Systems (ROS)
History
Physical Exam

Briefly and concisely summarize the H&P findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information.
Provide a differential diagnosis (minimum of 3) that might explain the patient’s chief complaint along with a brief statement of pathophysiology for each.
Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
Rank the differential in order of most likely to least likely.
Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must … supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is … also support this decision with EBM.

Part 2

Now, assume that you sent your patient for labs and she returns the following day, as instructed, to review the results.
CBC with differential
WBC 8.6 x10E3/uL
RBC 4.44 x 10E6/uL
Hemoglobin 14.0 g/dL
Hematocrit 41.2%
MCV 93fL
MCH 31.5 pg
MCHC 34.0 g/dL
RDW 13%
Platelet 241 x 10E3/uL
Neutrophils % 67%
Lymphocytes % 22%
Monocytes % 8%
Eosinophils % 3%
Basophils % 0%
Absolute Neutrophils 5.7 x 10E3/uL
… Lymphocytes 1.9 x 10E3/uL
Absolute Monocytes 0.7 x 10E3/uL
Eosinophils Absolute 0.3 x 10E3/uL
Basophile Absolute 0.0 x 10E3/uL
Immature Grans % 0%
Absolute Immature Grans 0.0 x 10E3/uL
TSH with Reflex to FT4
TSH 6.770 uIU/mL
FT4 0.62 ng/dL

PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago)
1. What is your primary diagnosis for this patient as the cause for the CC of fatigue? (support your decision for your diagnosis with pertinent positives and negatives from the case)
2. Identify the corresponding ICD-10 code.
3. Provide a treatment plan for this patient’s primary diagnosis which includes:
o Medication*
o .Any additional testing necessary for this particular diagnosis*
o Patient education*
o Referral
4. Provide an active problem list for this patient based on the information given in the case.
5. Are there any changes