One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
Brief introduction of the case
Identification of the main diagnosis with supporting rationale
Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
Diagnostic plan with supporting rationale or references
A specific treatment plan supported by recent clinical guidelines
Case Analysis Tool Worksheet
Student’s Name: Case ID: Internal Medicine 16: 45-year-old man who is overweight
I. Epidemiology/Patient Profile
Harrison James is a 45-year-old Caucasian male. He is obese. Denies smoking, but drink alcohol once a week.
II. Prioritized Cues from Hx and PE.(Do not include lab, x-‐ray, or other diagnostic test results here.) • Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem. • Tier 2: These are cues of intermediate importance (list only positive cues). • Tier 3: Of least importance (list only positive cues).
Tier 1 Tier 2 Tier 3 Weight 220lbs (BMI 34.5) Recent changes in personal life
(divorced from 2 years) No family history of diabetes
Last office visit: weight 208lbs (BMI 32.6)
Most men in the family gain weight over the years
Does not take any medication
Normal weight until a few years ago
Review of systems unremarkable
Waist circumference: 42 inches Usually eat a donut and coffee for breakfast, a burger and fries for lunch, and fast food for dinner Drinks a beer or two once a week Family history of hyperlipidemia and high blood pressure Father had heart attack at 68 year of age LDL- 141 mg/dL Total Cholesterol-206 mg/dL
III. Problem Statement
Harrison James, a 45-years-old Caucasian male, who is obese, came to clinic for a checkup. He is an accountant, and have a sedentary lifestyle both at work and home. His diet consists of coffee and a donut for breakfast, a burger and fries for lunch, and fast food for dinner. His weight is 220 lbs; and was 208 lbs at his last office visit. He denies exercising because he is too tired after work. He also reports being tired frequently and not able to fall asleep during the day, but able to sleep at night.
IV. Differential Diagnosis Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate.
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Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis.
Leading dx: Secondary Dyslipidemia (ICD 10: E78.5) (Grundy et al., 2018; Yang, 2018)
History Finding(s) Physical Exam Finding(s) obesity Weight 220lbs (BMI 34.5) Increased waist circumference Waist circumference- 42 inches Family history of hyperlipidemia and high blood pressure
LDL- 141 mg/dL Total Cholesterol-206 mg/dL
Unhealthy food: donut and coffee for breakfast, a burger and fries for lunch, and fast food for dinner
Review of system- unremarkable
sedentary lifestyle
Alternative dx: Metabolic Syndrome: ruled out because these patients usually have fasting blood glucose above 100. This patient’s blood glucose level is normal without medication. Moreover, patient does not meet the criteria for metabolic syndrome based on waist circumference, and triglyceride levels (Wang, 2020).
History Finding(s) Physical Exam Finding(s) Obesity, increased weight since last office visit Fasting glucose- 87 mg/dL
Unhealthy food: donut and coffee for breakfast, a burger and fries for lunch, and fast food for dinner
Waist circumference- 42 inches
Family history of hyperlipidemia and high blood pressure
Triglyceride- 136 mg/dL
sedentary lifestyle
Alternative dx: Diabetes: uncontrolled diabetes can secondary hyperlipidemia, but patient’s fasting blood glucose level was normal (Cash and Glass, 2017; Hill and Bordoni, 2021). Therefore, this differential diagnosis can be ruled out.
History Finding(s) Physical Exam Finding(s) Unhealthy food: donut and coffee for breakfast, a burger and fries for lunch, and fast food for dinner
Fasting blood glucose- 87 mg/dL
Obesity, increased weight since last office visit sedentary lifestyle
V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order:
Diagnostic Plan Rationale Repeat labs in 3 months:
– Fasting glucose – Fasting lipid profile
Since patient is not on drug therapy, and wants to control the cholesterol levels by lifestyle modifications; the total cholesterol should be
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– Hemoglobin A1c measured in 3 months to evaluate the progress and to determine initiating pharmacological approach (Cash and Glass, 2017).
Treatment Plan Rationale Nonpharmacologic interventions: (Yang, 2018) Lifestyle modifications:
– Weight loss – Increased physical activity – Increased dietary fiber – Reduction of saturated fats in diet
Lifestyle modifications are usually initiated before starting any pharmacological therapy. Weight loss, and diet can help lowering the cholesterol regardless of weight status (Yang, 2018).
Follow up in 3 months To reevaluate the lipid profile, and progress of weight, and diet ( Cash and Glass, 2017).
I have adhered to the honor system:
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References
Cash, J. C. & Glass, C. A. (2017). Family practice guidelines, (4th ed.). New York, NY: Springer LLC.
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de
Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A.,
Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A.,
Saseen, J. J., … Yeboah, J. (2019). 2018
AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the
Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guidelines. Circulation, 139(25), e1082–e1143.
https://doi.org/10.1161/CIR.0000000000000625
Hill, M. F., and Bordoni, B. (2021). Hyperlipidemia. StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK559182/
Wang, S. S. (2020). Metabolic syndrome. Medscape. https://emedicine.medscape.com/article/165124-overview
Yang, E. H. (2018). Lipid management guidelines. Medscape. https://emedicine.medscape.com/article/2500032-
overview#a3
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Aquifer Essay Title
Your Name
United States University
Course name
Instructor name
Date
Aquifer Essay Title
The introduction should be a paragraph that provides a brief overview of the case and main diagnosis with rationale and supporting evidence. You do not need to discuss pathophysiology or summarize the entire case. The entire paper should be between one and three pages long.
Differential Diagnoses
This section will identify your two differentials with the rationale and supporting evidence. Also explain why these differentials were not the main diagnosis.
Diagnostics
Identify the lab, radiology, or other tests needed for the main diagnosis with supporting evidence. Do not include excessive or non-pertinent testing.
Treatment, Education, and Follow-Up
This section should include the elements of an initial treatment plan for the main diagnosis. It should include medication names, dosages, frequencies; patient/family education; appropriate follow up plan; and hospitalizations and consults when appropriate.
References
The supporting evidence for this paper should be derived from at least two primary sources (not Medscape, UpToDate, Epocrates, etc.), including published clinical guidelines or peer-reviewed professional journals that are NOT textbooks. Supporting evidence should be published within the past 5 years, or 10 if the guidelines have not been updated. References should be in APA format. Refer to the APA 7 Manual for specific formatting requirements.
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