Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1 45-year-old woman, intermittent fevers.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care. Complete in Mini Soap note Format
Case Studies

1. Carl, a 56-year-old male, was hanging lights around his house today on a ladder when he turned sharply to catch a bulb and felt a sharp pull in his lower back. He presents to the clinic with a compensated gait, and is unable to sit due to discomfort. His vital signs are stable, and he has no medical history other than occasional allergies.
2. David, a 36-year-old male, presents to the clinic after an altercation last night in which he was in a fight after an evening of drinking heavily. He reports to you that he remembers punching another person in the mouth and cutting his hand, and also hitting a wall with the same hand. You notice that he also has several cuts on his lip and an abrasion over his eye. He is accompanied by his girlfriend who agrees with David’s account of the story, and denies any loss of consciousness or head injury. The patient returns from X-ray, with a report of a fracture to 2nd and 3rd MCP, or “boxer’s fractures,” to the right hand. He also has several lacerations over his knuckles that are jagged, and are most likely from teeth.
3. Anna is a 72-year-old diabetic patient on Metformin 1000mg twice daily who was bitten several times on her hands and legs by a neighborhood cat that she was feeding last night. She also received several scratches to her face and mouth, and she has several puncture marks to her hands.

The initial post is 300 words or more.
The writing is clear, concise, formal, and organized. Responses contain a maximum of 2 errors in spelling and grammar. Sources are paraphrased, referenced, and cited correctly in current APA style in all but 1 or 2 instances.
EXAMPLE

1 K is a 42-year-old female who runs marathons 3 to 4 times a year and maintains a very active lifestyle. She complains of decreased energy levels for the past 4 to 6 months with a six pound weight gain over the past six months and she has noted some hair loss in the shower. She states that she is sleeping well, but does not feel refreshed in the morning.

Demographic: 42 y/o female, good historian.
SUBJECTIVE
CC: “Decreased energy, weight gain and hair loss.”
To gain a more detailed picture of her health I would ask a series of questions including:
When did you first notice the symptoms?
When was your last menstrual period?
Have you had any changes in your menses?
Are you using any contraceptives?
Any possibilities to be pregnant?
Do you have a family history of thyroid disease?
What medications are you currently taking?
Have you had a sore throat or difficulty swallowing?
HPI: 42-year-old female patient presents to the office today reporting decreased energy for 4-6 months, 6 Lb weight gain within 6 months, tired in morning even after sleeping well, and noted some hair loss in the shower. No complaints of abdominal discomfort, nausea, vomiting or bladder problems. No fever, night sweats, chills or change in appetite.
Past Medical History: Denies past medical history
Medications: No current medications
Family History: non contributory
Allergies: NKDA
Hospitalizations: Denies hospitalization
Surgeries: Denies past surgeries
Immunizations: All childhood and adult vaccinations are up to date. COVID-19 vaccine, 4/2021, and 5/2021
Health maintenance: Last Pap smear 8/2021- Normal, Last physical 6/2021, Last eye exam 4/2021. Dental exam 4/2021
Review of Symptoms:
Constitutional: Decreased energy level, sleeps well, but not refreshed in the morning. 6 lbs weight gain. Denies change in diet. Denies fever, chills, night sweats
HEENT: Hair loss, Denies sore throat, difficulty swallowing, no headache, dizziness, vision changes, hearing changes, nasal congestion, sinus pain or rhinorrhea.
Lungs: Denies SOB, no pain, cough or wheezing.
Heart: Denies chest pain, dyspnea, edema, palpitations or syncope,
GI: Denies abdominal pain, tenderness and guarding. Denies constipation, diarrhea, nausea and vomiting.
Genitourinary/Gynecological: Denies frequent urination, urgency, pain, itching, and burning. Denies cloudy urine and blood in urine. Denies vaginal discharge, last pap smear was in 8/2021 WNL.
Musculoskeletal: Denies general weakness, clicking or popping, dislocations, pain radiating to abdomen/groin, or arthralgia.
Neurologic: Denies memory changes. Change in mood, not very happy or sociable.

OBJECTIVE:
VS T 98.7 BP 100/60, HR 56, RR 16, Weight 126 lbs, Height 5’4” BMI 21.6
General: A 42-year-old female AAOx 4, appears well groomed, healthy and nourished. Well developed. Appears tired but attentive.
Neck: Supple without adenopathy, No carotid bruits, trachea midline.
HEENT: Ear canals clear. TMs, bilaterally, gray in color. Good light reflex. Oropharynx pink and moist. No erythema or exudate. Some drainage is seen in the posterior pharynx. Nares: Swollen, red. No drainage seen. No sinus tenderness. Eyes are clear.
Respiratory: Respirations are regular and unlabored. Clear to auscultation throughout.
Cardiovascular: Regular even rhythm without murmur.
Breast: A round, smooth and easily movable lump with well distinct edges felt in the left breast. There is no pain in the area around the lump. No discharge noted from right and left nipple.
Skin: Warm, dry and pink, moist mucous membranes. No rash.
Gastrointestinal: Abdomen is round, skin intact, no lesion, no bulges visible. Normal active bowel sounds in all four quadrants.
Genitourinary: No itching, irritation, vaginal discharge, bleeding or discomfort. No pain or burning during urination, suprapubic pain, flank, hematuria, or dysuria. No urgency or hesitation on urination.
Musculoskeletal: No joint deformities and good ROM noted
Lymph Nodes: No lymphadenopathy in the axillae and neck.
Psychiatric: Maintains eye contact and responds to questions appropriately. She is very attentive and alert and oriented.
LABORATORY/POC Testing (performed in office)urine dip/pregnancy test
ASSESSMENT
Working Diagnosis: Hypothyroidism ICD-10 (E03.9)
Pertinent Positive: Decreased energy, weight gain and hair loss
Pertinent Negative: Depression, mood change fatigue, sleepiness, dry skin and constipation
Differential Diagnosis: Depression ICD-10 (Z13.31)
Pertinent Positive: Decreased energy, weight gain, hair loss
Pertinent Negative: maintains a very active lifestyle
Differential Diagnosis: Addison Disease ICD-10 (255.41)
Pertinent Positive: Fatigue, hair loss
Pertinent Negative: weight loss and decreased appetite
PLAN
Referrals: No referrals at this time
Treatment:
Diagnostic studies:

Standard precautions
Serum TSH, Total T4, Free T4, T3 (Ross, 2019)
Lipid panel for base line then annually (Hollier, 2018)
Medication: L-thyroxine 50mcg po Daily
Education: Lifelong adherence to thyroid medication and treatment
Non Pharmacological-
Provide a list of high fiber foods
Decrease foods high on cholesterol (Hollier, 2018)
Health maintenance: Tdap last 2018, HPV-completed series at age 12, flu shot 10/2021.
Referrals: No referrals at this time
Health Promotion
Provide education regarding smoking cessation
Maintain appropriate weight
Schedule patient for a complete physical exam
Psychosocial health screening (Ross, 2019)
RTC: Recheck TSH in 6 weeks after starting thyroid medication, then 6-8 weeks until at goal. Annual TSH unless patient is symptomatic (Hollier, 2018)