What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)
Identify the corresponding ICD-10 code.
Provide a treatment plan for this patient’s primary diagnosis which includes:
Medication*
Any additional testing necessary for this particular diagnosis*
Patient education
Referral
Provide an active problem list for this patient based on the information given in the case.
Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBM argument for each treatment or testing decision.
Provide an appropriate F/U plan.
*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 evidence-based medicine (EBM) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.
Case Study
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)
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