Case Study
An 82-year-old female presents to the office complaining of fatigue, dizziness, weakness, and increasing
dyspnea on exertion. She has a past medical history of atrial fibrillation, hypertension, and hyperlipidemia.
Medications include warfarin 2 milligrams po daily, lisinopril 10 milligrams po daily, and simvastatin 10 milligrams
po daily. There are no known drug allergies. The physical exam reveals a 5'2” older female. Her weight is 128
pounds, blood pressure is 144/80, heart rate is 98, temperature is 98 degrees Fahrenheit, and O2 saturation is
98%. Further examination reveals the following:
Eyes: + pallor conjunctiva
Cardiac: irregular rhythm. No S3 $4 or M. NO JVD
Lungs: CTA wio rales, wheezes, or rhonchi
Abdomen: soft, BS +, + epigastric tenderness. No organomegaly, rebound, or guarding
Rectal: no stool in rectal vault
- List the primary diagnosis
- List at least 3 differential diagnosis with a brief rational
- Describe the pertinent history required to rule in or rule out
- Describe your physical exam findings or screening tools used
- Discuss the treatment plan for the patient in your case study using this format
Sample Solution