Week 6: Discussion Part Two
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
Absolute 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)
• What is
your primary diagnosis for this patient as the cause for the CC of fatigue?
• Identify
the corresponding ICD-10 code.
• Provide a
treatment plan for this patient’s primary diagnosiswhich includes:
? Medication*
? Any
additional testing necessary for this particular diagnosis*
? Patient
education*
? Referral
and follow-up to the treatment plan
? Provide
an active problem list for this patient based on the information given in the
case.
Are there any changes that you would make to the patient’s
overall plan at this time? Must provide an evidence-based medicine (EBM)
argument to support any treatments or testing decisions.
Provide an appropriate follow-up plan (include any
additional testing that you feel is necessary and include an EBM argument).
*If part of the plan does not warrant an action, you must
explain why. ALL medication and testing decisions (or decisions not to treat
with medication or additional testing) MUST be supported with an EBM argument.
