Patient Analysis and diagnosis are important in the medical field. Natalie Grant is a patient that has a complain about her skin condition. Below is an ihuman case study that shows her diagnosis and results.
Patient: Natalie Grant
Exam
BP 106/72 orthostatic 84/58
pulse 112
resp 20
temp 98.4
spo2 97%
Inspect skin all over: Skin warm, dry. Decreased turgor.
Large erythematous confluent patches (with satellite lesions) under both breasts, consistent with candida intertrigo
Hair thickness and distribution: Thickness and distribution pattern typical for patient gender and age.
Inspect eyes: Sclera and conjunctiva normal, nonicteric
Test visual acuity: Visual acuity with Snellen pocket card: right eye 20/20, left eye 20/20
Bilateral PERRLA
Fundoscopic exam is normal
Smell breath: no unusual odor
Breast exam: Breasts normal appearance, symmetrical, no masses palpable, no nipple discharge. Large erythematous confluent patches (with satellite lesions) under both breasts, consistent with candida intertrigo
Visual inspection of abdomen: Protuberant abdomen consistent with obesity. No evidence of scars, bruises, hernia, or lesions. Abdomen girth: morbidly obese
Visual inspection of extremities: feet warm, adequately perfused, no peripheral edema, no signs of infection
Sensory tests: decreased sensation in the feet of the level of the ankle bilaterally. Decreased light touch, position, and vibratory sensation in the feet to the level of the ankle bilaterally.
Female genitourinary exam: normal external genitalia, no masses or tenderness, normal pelvic exam
- Abdomen: palpate abdomen
Abdomen is soft to palpation without tenderness in all 4 quadrants. Liver edge is felt below the coastal margin with inspiration and is smooth. Liver span normal to percussion. Spleen not palpable. No masses or organomegaly. No herniation. Aorta size difficult to palpate.
- Musculoskeletal: test strength
Motor strength decreased 3/5 throughout secondary to low effort/fatigue
- Neurological: reflex tests - deep tendon
2+ bilaterally
- Neurological: cranial nerves
Cranial nerves intact
- Neurological: gait & stance
Normal gait and posture
- Abdomen: auscultate abdomen- normal
- Vitals: Mental Status- a&o x 4
- HEENT: inspect mouth/pharynx: Dry mucus membranes, good dental hygiene
- Neck: palpate neck:
- Neck: measure JVP (jugular venous pressure)
Flat jugular veins
- Neurological: monofilament test
Decreased sensation bilaterally to the level of the ankles
- Rectal: rectal exam
Normal sphincter tone. No rectal mass. Stool brown, guaiac negative
Problem statement
45 year old female presents with worsening fatigue and lightheadedness on standing. She has a history of HTN, osteoarthritis of both knees, a 20 pack year history of smoking, and obesity. She takes ibuprofen for her knees and had been noncompliant with her amlodipine and hydrochlorothiazide since losing her insurance. She complains of trouble sleeping due to nocturia and reports polyuria and polydipsia during the day. She has also had some blurred vision recently, a 10-pound unintentional weight loss, and reports a rash under her both breasts. Physical exam is significant for tachycardia of 110, orthostatic hypotension, decreased skin turgor, dry mucus membranes, and decreased sensation to BLE below the ankles.
| Tests | |||||||||||||||||||||||||
| BMP | |||||||||||||||||||||||||
| Name | Value | Units | Reference Range | ||||||||||||||||||||||
| Sodium (Na+) | 148 | mmol/L | 135-145 | ||||||||||||||||||||||
| Potassium (K+) | 4.5 | mmol/L | 3.5 to 5.1 | ||||||||||||||||||||||
| Chloride (Cl-) | 96 | mmol/L | 95-102(1mo-adult), 91-118(1d- | ||||||||||||||||||||||
| 1mo) | |||||||||||||||||||||||||
| Carbon dioxide, total | 22 | mmol/L | 22-29(15y-adult), 20-28(1y-15y) | ||||||||||||||||||||||
| (CO2) | |||||||||||||||||||||||||
| 70-110(fasting), 70-130(non- | |||||||||||||||||||||||||
| Glucose (BG/Glu) | 566 | mg/dL | |||||||||||||||||||||||
| fasting) | |||||||||||||||||||||||||
| Urea nitrogen (BUN) | 86 | mg/dL | 8-21(15y-adult), 5-18(1mo-15y) | ||||||||||||||||||||||
| Creatinine (Cr) | 1.5 | mg/dL | ♂ | ♀ | |||||||||||||||||||||
| 0.6-1.3( | ), 0.5-1.1( | ) | |||||||||||||||||||||||
| Calcium (Ca2+) | 10 | mg/dL | 8.7-10.7(1 mo-adult), 8.7-11.9 | ||||||||||||||||||||||
| *Anion Gap | 30 | mEq/L | 10-20 [(Na+ + K+) - (Cl- + HCO3-)] | ||||||||||||||||||||||
Severe hyperglycemia, hypernatremia, elevated BUN to creatinine ratio (57), prerenal azotemia (no baseline for comparison). Elevated anion gap (30), rule out lactic acidosis
| CBC | ||||
| Name | Value | Units | Reference Range | |
| White blood cells (WBCs) | 9700 | mm3 | 4,000-10,000 | |
| Red Blood Cell Count (RBC) | 5.1 | million/µl | 4.5-5.9(♂), 4.0-5.2(♀), adults | |
| Hemoglobin (Hgb) | 16 | g/dl | 14-18(♂), 12-16(♀), adults | |
| Hematocrit (Hct) | 49 | % | 42-54(♂), 37-47(♀), adults | |
| Mean corpuscular volume (MCV) | 94 | fl | 82-103, adults | |
| Mean corpuscular hemoglobin (MCH) | 32 | µm3 | 26-34, adults | |
| Mean corpuscular hemoglobin concentration | 31 | % | 30-37, adults | |
| (MCHC) | ||||
| Platelets (thrombocytes) | 363 | k/dL | 150-399, adults | |
| Red cell distribution width (RDW) | 12.8 | % | 11.5-14.5, adults | |
| Neutrophils | 64 | % | 46-78, adult | |
| Lymphocytes | 29 | % | 18-52, adult | |
| Monocytes | 5 | % | 3-10, adult | |
| Eosinophils | 1 | % | 0-6, adult | |
| Basophils | 1 | % | 0-3, adult | |
| Segmented neutrophils | 60 | % | 36-72, adult |
| Band Cells | 4 | % | 0-6, adult |
Hb and Hct at upper limits of normal, suspect hemoconcentration effect
EKG:
Sinus tachycardia, no evidence of acute or chronic ischemia, left ventricular hypertrophy, possibly secondary to longstanding hypertension.
| Hgb A1C 10.3 | ||||||||||
| Urinalysis | ||||||||||
| Name | Value | Units | Reference Range | |||||||
| Color | very pale | Interpreted by physician | ||||||||
| yellow | ||||||||||
| Clarity | clear | clear | ||||||||
| Odor | normal | slightly nutty | ||||||||
| pH | 5.6 | 4.5-8 | ||||||||
| Protein | 7 | mg/dL | 0-8 | |||||||
| Specific gravity | 1.030 | 1.002-1.030 | ||||||||
| Osmolarity | >800 | mOsm/L | >400 | |||||||
| Leukocyte esterase | negative | negative | ||||||||
| Nitrites | negative | 0 | ||||||||
| Ketones | negative | negative | ||||||||
| Bilirubin | negative | negative | ||||||||
| Blood (heme) | negative | |||
| Urobilinogen | 0.9 | |||
| Crystals | none | |||
| Casts | 3 | |||
| Glucose, urine | +4 | |||
| White blood cells | 0-1 | |||
| (WBCs) | ||||
| Red blood cells (RBCs) | 0-1 | |||
| Red blood cell casts | none | |||
| SQEP | none | |||
| Bacteria | negative | |||
| Creatinine | 18 | |||
| Occult blood | negative | |||
Dilute urine, glucosuria without ketonuria EU/dL
hyaline
casts/lpf
hpf
hpf
lpf
negative
0.2-1.0
Intergreted by physician
0-4
negative
0-5
0-5
none
<5
negative on spun
specimen
5-19
negative
| Fasting Lipid panel | ||||||||
| Name | Value | Units | Reference Range | |||||
| Cholesterol | 250 | mg/dL | low risk <200, moderate 200-239, high | |||||
| High-density lipoprotein | ||||||||||
| 40 | mg/dL | |||||||||
| (HDL) | ||||||||||
| Low-density lipoprotein (LDL) | 165 | units/L | ||||||||
| Triglycerides | 200 | mg/dL | ||||||||
>239
maj risk <40, neg risk >59
low risk <130, moderate 130-159, high >159
(♀) 35-135, (♂) 40-160
Hypercholesterolemia, hypertriglyceridemia and low HDL
Anti GAD antibody (glutamic acid dehydronase) 1.5 (normal)
Hemoglobin A1c is a measure of blood glucose over the past approximately three months
BMP is used to measure glucose in addition to kidney function which may be elevated in diabetics. The anion gap is also measure which could indicate ketoacidosis or lactic acidosis.
UA is used in diabetics to determine if ketones and glucose are present and is also used to look for infection as infection is more common in diabetics.
lipid panel is used to measure LDL, HDL and triglycerides as dyslipidemia is common in type 2 diabetics 12 lead ekg is used as a baseline assessment that can indicate ischemic changes
Diagnostic laboratory results include:
Fasting plasma glucose greater than 126 mg/dL 2 hour plasma glucose greater than 199 mg/dL Hgb A1c greater than 6.4%
Get Ihuman Case Studies from our professional tutors www.acemyhomework.com. Our tutors are readily available and at your service 24/7. You'll get plagiarism free papers, dissertations and essays. Place your order today at https://acemyhomework.com/order-now
