Assignment Prompt & Instructions
– 2 years ago
**files (1)**
– ## Week6casestudy2.docx
**## Week6casestudy2.docx**
Week 6 case study
Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states that in 1985 she received a blood transfusion after sustained an MVA. She had tested positive for hepatitis C virus ( HCV ) in the past, but ignored any advice regarding treatment options. She brings a previous lab result with her today that shows :(ALT) level of 85 IU/mL (range 8 – 35 IU/mL). The lab form also states, “ HCV antibody is positive by enzyme immunoassay — confirmation is suggested. The patient also arrived with diagnosis with exacerbation of A-Fib (pulse 110 beats per mint. and COPD exacerbation as well (O2 sat: 87%)
Past medical h story: Hypertension, dyslipidemia, hepatitis C.
Family history: Unremarkable
Social history: She works as a case manager of an HMO and is married with 2 children. Denies use of illegal drugs, denies alcohol abuse, and has no tattoos.
Medications: HCTZ, 12,5 mg daily; Atorvastatin 20 mg daily, Metoprolol Succinate 25 mg and Pro-Air HFA 90mcg one puff q 4- 6 hrs as needed x pain.
Allergies: No known drug or food allergies.
OBJECTIVE General a ppearance: 58 – year – old female; pleasant, in no acute distress; good eye contact. Vital signs: T: 96.8; P: 110; RR: 23; SaO 2 : 87; BP: 150/100. Her weight is 214 lb, and her height is 6.3 inches.
HEENT : Negative. Neck: Thyroid nonpalpable. No lymphadenopathy.
Cardiovascular: A-fib rhythm. irregular and rapid heartbeat.
Respiratory: Crackles and Wheezing.
Abdomen: Mild tenderness in right upper quadrant. BS x 4 no bruits. Nondistended, soft. No organomegaly. No ascites.
Neurological: A & O × 4, CN II – XII grossly intact.
Depression scale: negative. Musculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.
**CRITICAL THINKING**
**Which diagnostic or imaging studies should be considered confirm the**
**diagnosis?**
**What is the most likely differential diagnosis?**
**What is your plan of treatment?**
**Are there any emergency referrals needed?**
**What is first line treatment for AFib in patients with the mentioned comorbidities?**
**What is the first line of treatment for COPD exacerbation?**
**Apa seven plagiarism less than 20%**
**## Week6casestudy2.docx**
Week 6 case study
Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states that in 1985 she received a blood transfusion after sustained an MVA. She had tested positive for hepatitis C virus ( HCV ) in the past, but ignored any advice regarding treatment options. She brings a previous lab result with her today that shows :(ALT) level of 85 IU/mL (range 8 – 35 IU/mL). The lab form also states, “ HCV antibody is positive by enzyme immunoassay — confirmation is suggested. The patient also arrived with diagnosis with exacerbation of A-Fib (pulse 110 beats per mint. and COPD exacerbation as well (O2 sat: 87%)
Past medical h story: Hypertension, dyslipidemia, hepatitis C.
Family history: Unremarkable
Social history: She works as a case manager of an HMO and is married with 2 children. Denies use of illegal drugs, denies alcohol abuse, and has no tattoos.
Medications: HCTZ, 12,5 mg daily; Atorvastatin 20 mg daily, Metoprolol Succinate 25 mg and Pro-Air HFA 90mcg one puff q 4- 6 hrs as needed x pain.
Allergies: No known drug or food allergies.
OBJECTIVE General a ppearance: 58 – year – old female; pleasant, in no acute distress; good eye contact. Vital signs: T: 96.8; P: 110; RR: 23; SaO 2 : 87; BP: 150/100. Her weight is 214 lb, and her height is 6.3 inches.
HEENT : Negative. Neck: Thyroid nonpalpable. No lymphadenopathy.
Cardiovascular: A-fib rhythm. irregular and rapid heartbeat.
Respiratory: Crackles and Wheezing.
Abdomen: Mild tenderness in right upper quadrant. BS x 4 no bruits. Nondistended, soft. No organomegaly. No ascites.
Neurological: A & O × 4, CN II – XII grossly intact.
Depression scale: negative. Musculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.
**CRITICAL THINKING**
**Which diagnostic or imaging studies should be considered confirm the**
**diagnosis?**
**What is the most likely differential diagnosis?**
**What is your plan of treatment?**
**Are there any emergency referrals needed?**
**What is first line treatment for AFib in patients with the mentioned comorbidities?**
**What is the first line of treatment for COPD exacerbation?**
**Apa seven plagiarism less than 20%**