- Use the following case study.
- Complete the corresponding “Differentials Table” to align your clinical reasoning – include 5 differentials (excluding the example provided).
- In SOAP format, discuss what questions you would ask the patient (Review of Systems), what physical exam elements you would include, what further testing you would want to have performed (if any), differential and working diagnosis, treatment plan, including the addition of complementary and OTC therapy, referrals and other team members needed to complete patient care.
CASE STUDY: Mildred is a 45-year-old married female with three children. She presents to the clinic with complaints of fatigue and difficulty sleeping. She states she wants to get a good night’s sleep and is requesting a prescription to help her sleep. Mildred tells you she is awake off and on during the night, frequently thinking about her husband’s recent layoff from construction work and the effect this is having on the family. She lies down often during the day and has been so fatigued that she took some time off from work during the last two weeks. She is tearful at times during the visit and looks sad and anxious. On further discussion, she says she feels overwhelmed, helpless, and anxious. She tells you about an episode where she felt her heart beating rapidly, had difficulty catching her breath, felt she was going to have a heart attack, and became frightened until her husband was able to help calm her down. She is not eating as much as usual, and when she reads the newspaper, she does not remember what she has read.
DIFFERENTIALS TABLE:
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Differential |
Signs/Symptoms |
Gold Standard Diagnostics |
Gold Standard Treatment |
|
Ex: PTSD |
Flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, agoraphobia, sleep disturbance and hypervigilance, feelings of detachment. |
Clinician-Administered PTSD Scale (CAPS-5) |
First-line treatment with a trauma-focused psychotherapy such as eye movement desensitization and reprocessing (EMDR). In individuals with comorbid disorders (ex., depression, psychosis) that affect the person’s ability to work in trauma-focused therapy (ex., concentration, motivation), treat with pharmacologic management; SSRI first line such as sertraline or paroxetine. |
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