Create a list of three to five

Create a list of three to five differential diagnosis based on the patient’s presentation, HPI, and PE. Explain, for each differential diagnosis, what in the presentation, HPI, or PE led to your decision to select the differential diagnosis that you chose. (Medical Decision Making) Select the most likely diagnosis you think the patient could have and select a second possible diagnosis. Create a pathophysiology concept map/ flow chart. In that flow chart compare and contrast these two diagnoses documenting how the two diagnoses are similar in looking at their symptoms, physical examination and labs, and document how the two diagnoses are different. Also answer these additional questions: Analyze and write a brief paragraph or list indicating what your differential diagnoses list could include (list all other possible diagnoses) if your patient is (1) 9 years old or if the patient were (2) a female patient (ie. how might your ddx change). Use evidence based information with citations to support your answers. Gastrointestinal Case Study CC: 82-year-old male complaining of having persistent weakness, fatigue, lack of energy for the past five weeks. HPI: Started about five weeks ago with gradual onset of fatigue. Happens all day long no matter how much sleep he gets. Also, states that he seems to be having more heartburn, more often despite his daily medication for GERD. Nothing makes it better or worse- tried sleeping more and taking energy vitamins. Denies vomiting but does have occasional nausea and does say he’s also lost eight pounds in the last month without any diet or exercise changes. PMH: GERD, Asthma and benign prostatic hyperplasia (BPH) Meds: Omeprazole 20mg po daily, Advair Diskus 1 puff q 12 hours, Albuterol MDI 2 puffs q 4 hours PRN, Terazosin 1 mg q hs. FH: Mother deceased at age 86 with type 2 diabetes and hypertension, father died of an acute MI at age 59, he has two sisters, ages 74 and 77 who are alive and well. My maternal grandmother died from breast cancer and an aunt died from college complications due to colon cancer. SH: Retired music professor and lives alone since his wife passed away two years ago. He smokes 1 1/2 packs of cigarettes and drinks 3-4 Brandy Manhattans daily. He eats a lot of hamburgers and processed meats, especially dry-cured salami. Minimal grain products and occasionally fruit. The only vegetables consumed regularly are potatoes and carrots. Does not exercise regularly but does some light walking a few times a week. 2 Allergies: Aspirin (causes upset stomach), no material or environmental allergies ROS: General: no fevers, night sweats, +fatigue, + weight loss Skin: Denies changes in lesions /moles or any rashes. HEENT: denies vision changes, needs to use readers for up close, denies eye discharge, denies nasal congestion or sneezing, denies hearing changes or ear pain, or sore throat. Cardio: denies chest pain, palpitations, orthopnea, DOE or edema. Pulmonary: denies cough or shortness of breath GI: denies abdominal pain, denies vomiting, and constipation. +nausea with pain. GU: Denies increase in urination, pain or frequency. MSK/Neuro: Denies joint pain or loss of range of motion, denies numbness tingling or changes in sensation, + does feel weaker overall though. Psych: Denies depression, however, is a bit anxious about what might be going on. VS: BP: 120/90 P: 78 RR: 15 T: 98.6 Ht: 5’6″ Wt: 202lbs O2 sat: 96% r/a PE: General: pleasant, elderly overweight male, in no apparent distress. Appears stated age. Flat affect. Skin: Warm and dry, ruddy complexion. No lesions, bruising or discoloration. Normal turgor. HEENT: Slightly pale conjunctiva, eyes without discharge, ears with moderate cerumen, TM’S intact, mouth moist, w/o lesions, tonsils 2+ no erythema, nares patent bilaterally, no d/c. Thyroid non-palpable. No LAD. Heart: Regular rhythm, no murmurs, rubs or gallops. Lungs: CTA Bilat. Resonant breath sounds, no crackles. Abdominal: Soft, round, non-tender to palpation. BS all quadrants, tender to palpation in an epigastric region otherwise no HSM. MASK/ Neuro: spooning of fingernails, no cyanosis, full range of motion of upper and lower extremities, strength4+/5, deep smooth, no pedal edema. CNII-IX intact, DTR’s 2+, no sensory deficits. POC test today: Hemoglobin 10.1g/dl Fecal Occult blood (FOB) is + for blood in stool Outside labs: CBC (RBC 3.2, Hmg10.1/ Hct 31%, microcytic hypochromic) Ferritin = 8 H. Pylori breath test is + SCIENCE

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