The purpose of the Aquifer assignment is to teach you how to synthesize important patient information gathered during an office visit to select appropriate differentials and create subsequent diagnostic and treatment plans.
The Aquifer assignment is not a summarization of the Aquifer case, or an essay on the specific illness/disease presented.
The written portion of the Aquifer assignment should clearly outline your rationale for selecting your leading diagnosis and differentials, given the information collected for the patient presented.
While the write up needs to include an appropriately formatted title page per APA 7 guidelines, a formal introduction and conclusion are not needed.
An example outline of the written assignment should include would be as follows:
Leading Diagnosis
(this is the diagnosis for which diagnostic and treatment plan will be written)
The leading diagnosis for this patient is ****. Leading diagnosis is supported by patient’s presenting symptoms of ***** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). Supporting physical assessment findings include ****** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Differential Diagnoses (must have 2 differentials)
Differential 1 (e.g. Influeza)
The first differential in this case is **** supported by patient presentation of *** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). The differential is further supported by physical exam findings of **** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). *** is less likely however due *(here you would present s/s, history physical exam findings that rule out differential)* (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Differential 2 (e.g. Viral pharyngitis)
*** is the second possible differential in this case. Differential is supported by patient’s presenting symptoms of **** (citation). Patient’s physical assessment findings of *** further support the differential however, differential is less likely due to *** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Diagnostics
Here you would outline your diagnostic plan including any pertinent diagnostic test(s) or exam(s) indicated for diagnosis (must include citation of a Clinical Practice Guideline unless not available. If no guideline is available may use a Problem Specific Peer Reviewed Reference). Brief statement regarding why test is being used, e.g. Positive RADT results are confirmatory for GAS in pediatric patients (Clinical Practice Guideline or Problem Specific Peer Reviewed Reference citation).
Treatment Plan
*** is the first line treatment for *** (must include citation of a Clinical Practice Guideline unless not available. If no guideline is available may use a Problem Specific Peer Reviewed Reference) Any medications should include name, route, dose, and duration (Clinical Practice Guideline or Problem Specific Peer Reviewed Reference citation). Supportive measures recommended, including ***** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). Follow up **** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings)
References (documented per APA 7 guidelines)
Must include an appropriate clinical practice guideline unless there is not a written guideline for diagnosis. In the case no guideline is available a peer reviewed article written on the specific diagnosis selected may be used.
Aquifer Case Study #18 Family Medicine: Migraine Headaches without Aura
Student
United States University
FNP 591: Common Illnesses Across the Lifespan
Professor Georgia Strong
June 01, 2022
Leading diagnosis
The leading diagnosis for S.P. is migraine headaches without aura. A diagnosis of migraine headaches without aura is supported by the patient’s report of unilateral and severe throbbing pain associated with nausea, photophobia, and hyperacusis occurring 2-3 times weekly (Cutrer, 2022). S.P meets 5 of the ICHD-3 diagnostic criteria for migraine without aura, including 1) having 5 attacks 2) headache attacks that last 4-72 hours, 3) characteristics such as unilateral pulsating headache, 4) nausea, vomiting, and photophobia during headache, and 5) does not match other ICHD-3 diagnosis (Cutrer, 2022).
Differential Diagnoses
Differential diagnoses for this patient include cluster-type headaches and anxiety.
Cluster-Type Headaches
The first differential for S.P. is cluster-type headaches, supported by a debilitating unilateral and severe throbbing pain that’s associated with nausea, photophobia, and hyperacusis that occurs 2-3 times a week and results in the patient having to go home. However, this is ruled out due to lack of autonomic symptoms such as ptosis, miosis, lacrimation, conjunctival injection, sweating, and/or nasal congestion (May, 2022).
Anxiety
Another differential is headache due to anxiety supported by S.P. ‘s report of a stressful lifestyle with schooling, part time work, and recent breakup with a boyfriend who cheated. (Taylor, 2020). However, this is ruled out as the patient’s GAD-2 score was 2, testing negative (Taylor, 2020).
Diagnostics
Diagnostic testing of MRI for migraine isn’t needed in this patient given her age of under 50 or having cognitive changes (Ng & Hanna, 2021). The patient would not need other laboratory tests given the negative physical examination (Cutrer, 2022).
Treatment Plan
S.P. ‘s migraine can be treated with oral sumatriptan 100 mg PO as needed for headaches and can be repeated in 2 hours, but do not exceed over 200 mg in a 24-hour period (Ng & Hanna, 2021). The patient can also take a combo therapy of acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg orally PRN for tension-type headaches (Taylor, 2020). The patient should reduce her caffeine intake from other sources if it’s a trigger for her headaches.
S.P. should have a follow up appointment in 2 weeks to see if the medication worked. The patient in the meantime should keep a journal of headache triggers and patterns and reduce stressors in her life that could contribute to the tension-type headaches. She can also exercise four times a week, use relaxation therapies, and improve sleep (Schwedt & Garza, 2022).
References
Cutrer, M. (2020). Pathophysiology, clinical manifestations, and diagnosis of migraine in adults. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-migraine-in-adults?search=migraine&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
May, A. (2022). Cluster headache: Epidemiology, clinical features, and diagnosis. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/cluster-headache-epidemiology-clinical-features-and-diagnosis?search=cluster%20headache&source=search_result&selectedTitle=1~47&usage_type=default&display_rank=1#H6
Ng, J. Y., & Hanna, C. (2021). Headache and migraine clinical practice guidelines: A systematic review and assessment of Complementary and Alternative Medicine Recommendations. BMC Complementary Medicine and Therapies, 21(1). https://doi.org/10.1186/s12906-021-03401-3
Schwedt, T. & Garza, I. (2020). Acute treatment of migraine in adults. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults?search=migraine%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7
Taylor, F. (2020). Tension-type headache in adults: Acute treatment. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/tension-type-headache-in-adults-acute-treatment?search=tension%20headache&topicRef=3357&source=see_link#H8
Aquifer Week Eight: Family Medicine 17
Student
United States University: FNP591 Common Illness Across the Lifespan
Professor
December 19, 2022
Case Analysis Tool Worksheet
Student’s Name: Student Case ID: Student_AQ_17
I. Epidemiology/Patient Profile
Mrs. Parker is a 55-year-old Caucasian female with two weeks of intermittent vaginal bleeding. She has received hormone replacement therapy since menopause (HRT). She is obese and has a history of hypertension and hypothyroidism for which she takes Lisinopril and Synthroid.
II. Prioritized Cues from History and PE.
Tier 1 Tier 2 Tier 3
55-year-old female, G2P2 Menarche age 11 Hypertension
Intermittent vaginal bleeding for the past two weeks Obesity 36kg/m2 Family history of osteoporosis, HTN, DM (mother)
Postmenopausal Father history of Heart failure
Bleeding was sufficient to wear a pad Several maternal aunts HTN, DM
Bright red x 4 days, then brown discharge (like a normal period) Paternal grandfather heart attack
Bloating
PMH: hypothyroidism treated with levothyroxine medication.
Estrogen hormone replacement
The thyroid is normal in size and no nodules.
Hot flashes
No abdominal cramping
No abnormal pap smears
The thyroid is normal in size and no nodules.
The vaginal dome appears shiny and free of malignancy, but the vaginal wall is still folded inward, resulting in a reduced number of rugae. Similar to the ovaries, the cervix is silky and bloody with no abnormalities
There are no sores on the labia and minimal pubic hair on the external genitalia
Small blood vessels and an os can be removed with wipes from the surface of the cervix, which is smooth. On the cervix, there are no tumors.
There is a small bit of red blood at the cervix, but it is easily removed.
Her ovaries were inaccessible due to her being overweight, but her cervix was free to move and not sensitive.
Mrs. Parker, a 55-year-old menopause cisgender female, has experienced intermittent vaginal bleeding for the previous two weeks. The bleeding is comparable to a typical period, consisting of four days of bright red blood followed by brown discharge, and it is severe enough that a pad must be used. She has stomach distention but denies having abdominal cramps. Menarche began at the age of 11, past pap smears have all been normal, and she has no family history of malignancy.
III. Problem Statement
IV. Differential Diagnosis
Leading dx: Proliferative Endometrium/Endometrium (Singh & Puckett, 2020)
History Finding(s) Physical Exam Finding(s)
Light vaginal bleeding for two weeks with no associated cramps. Thin pubic hair. Red blood not at the cervix, easily wiped away. Vaginal vault has decreased rugae with a shiny appearance. Cervix is smooth with a small os with a small amount of blood with no lesions. Cervix is freely movable and non-tender.
Menarche at 11, LMP: 3 years ago, G2P2 PE: Abdomen: Her bowel sounds are normal and there is no hepatomegaly or other masses appreciated. Although her abdomen is obese, she is not distended. There is also no abdominal tenderness
Med list: Levothyroxine 100 mcg daily, Lisinopril 20 mg daily, Estrogen/medroxyprogesterone 0.625/2.5 mg daily PE: HEENT: Pupils are equal, round, and reactive to light. Thyroid: No nodules and a normal size thyroid.
Pap smear 4 years ago and result was normal Vital signs: BP 132/80 mmHg, PR 88, Weight 95.3 kg, Height 163 cm BMI=36.
No family history of cancers Normal. HPV high-risk testing negative
PMH: Menopause, hypertension, hypothyroidism, and obesity. Ultrasound: The uterus is normal size, endometrial stripe is 6mm, with no lesions. Ovaries are normal size and morphology for age.
TSH: 1.0 U/mL
Hgb: 13.4g/dL, Plts: 350,000/uL
Endometrial Biopsy: Confirms proliferative endometrium
Alternative dx: Endometrial Cancer (Braun et al., 2016)
History Finding(s) Physical Exam Finding(s)
Light vaginal bleeding for two weeks with no associated cramps. Thin pubic hair. Red blood not at the cervix, easily wiped away. Vaginal vault has decreased rugae with a shiny appearance. Cervix is smooth with a small os with a small amount of blood with no lesions. Cervix is freely movable and non-tender.
Menarche at 11, LMP: 3 years ago, G2P2 PE: Abdomen: Her bowel sounds are normal and there is no hepatomegaly or other masses appreciated. Although her abdomen is obese, she is not distended. There is also no abdominal tenderness
Med list: Levothyroxine 100 mcg daily, Lisinopril 20 mg daily, Estrogen/medroxyprogesterone 0.625/2.5 mg daily PE: HEENT: Pupils are equal, round, and reactive to light. Thyroid: No nodules and a normal size thyroid.
Pap smear 4 years ago and result was normal Vital signs: BP 132/80 mmHg, PR 88, Weight 95.3 kg, Height 163 cm BMI=36.
No family history of cancers Normal. HPV high-risk testing negative
PMH: Menopause, hypertension, hypothyroidism, and obesity. Ultrasound: The uterus is normal size, endometrial stripe is 6mm, with no lesions. Ovaries are normal size and morphology for age.
TSH: 1.0 U/mL
Alternative dx: Cervical polyps (Alkilani & Apodaca-Ramos, 2021)
History Finding(s) Physical Exam Finding(s)
Light vaginal bleeding for two weeks with no associated cramps. Thin pubic hair. Red blood not at the cervix, easily wiped away. Vaginal vault has decreased rugae with a shiny appearance. Cervix is smooth with a small os with a small amount of blood with no lesions. Cervix is freely movable and non-tender.
Menarche at 11, LMP: 3 years ago, G2P2 PE: Abdomen: Her bowel sounds are normal and there is no hepatomegaly or other masses appreciated. Although her abdomen is obese, she is not distended. There is also no abdominal tenderness
Med list: Levothyroxine 100 mcg daily, Lisinopril 20 mg daily, Estrogen/medroxyprogesterone 0.625/2.5 mg daily PE: HEENT: Pupils are equal, round, and reactive to light. Thyroid: No nodules and a normal size thyroid.
Pap smear 4 years ago and result was normal Vital signs: BP 132/80 mmHg, PR 88, Weight 95.3 kg, Height 163 cm BMI=36.
No family history of cancers Normal. HPV high-risk testing negative
PMH: Menopause, hypertension, hypothyroidism, and obesity. Ultrasound: The uterus is normal size, endometrial stripe is 6mm, with no lesions. Ovaries are normal size and morphology for age.
TSH: 1.0 U/mL
Hgb: 13.4g/dL, Plts: 350,000/uL
V. Explanation of Diagnostic Plan and Treatment Plan in prioritized order:
Diagnostic Plan Rationale
Pap smear with HPV In conjunction with human papillomavirus (HPV), cervical cytology is used for cervical cancer screening. It can detect both low-grade and high-grade squamous intraepithelial lesions (LSIL and HSIL, respectively) (HSIL). She is due for a repeat pap smear and cytologic assessment to rule out cervical cancer (Cash & Glass, 2020).
Complete Blood Count (CBC) To rule out anemia and thrombocytopenia
Thyroid Stimulating Hormone (TSH) To determine TSH level .Thyroid disorders may result in abnormal bleeding. (Cash & Glass, 2020).
Mammogram To screen for breast cancer. Recommended every 1 to 2 years for women over 50 at average risk for breast cancer (Qaseem et al., 2019).
Transvaginal Ultrasound (TVUS) Initial test that is economical for evaluating the thickness of the endometrium. Transvaginal ultrasonography (TVUS) endometrial thickness measurement is a noninvasive approach for evaluating individuals with postmenopausal bleeding for endometrial hyperplasia or malignancy (Singh & Puckett, 2020).
Endometrial biopsy Highly recommended for women with uncontrolled menstrual bleeding (Singh & Puckett, 2020).
Treatment Plan Rationale
Discontinue HRT Estrogen treatment increases endometrial thickness (Singh & Puckett, 2020).
Calcium 1,200 mg take 1 tablet PO daily Necessary for the development and maintenance of strong bones (Rosen et al., 2022).
Vitamin D 800-1000 IU daily. Necessary for the development and maintenance of strong bones (Rosen et al., 2022).
Create a weight bearing exercise plan that is right for the patient. Strengthening muscles and bones, and preventing additional bone loss, is the primary function of exercise (Cash & Glass, 2020).
Encourage the patient to eat a regular well-balanced diet. Increasing dietary protein, vitamin D, and calcium helps strengthen bones (Cash & Glass, 2020).
Follow up in 3 months or sooner if vaginal bleeding continues
I have adhered to the honor system: Yes
Student’s signature
References
Alkilani, Y. G., & Apodaca-Ramos, I. (2021). Cervical polyps. PubMed. https://www.ncbi.nlm.nih.gov/books/NBK562185/
Braun, M. M., Overbeek-Wager, E. A., & Grumbo, R. J. (2016). Diagnosis and management of endometrial cancer. American Family Physician, 93(6), 468–474. https://www.aafp.org/pubs/afp/issues/2016/0315/p468.html
Cash, J. C., & Glass, C. A. (2020). Family practice guidelines (4th ed.). Springer Publishing Company, LLC.
Qaseem, A., Lin, J. S., Mustafa, R. A., Horwitch, C. A., & Wilt, T. J. (2019). Screening for breast cancer in average-risk women: a guidance statement from the American College of Physicians. Annals of internal medicine, 170(8), 547-560.
Rosen, H., Rosen, C., Schmader, K. E. & Mulder, J. E. (2022). Calcium and vitamin D supplementation in osteoporosis. UpToDate. https://www.uptodate.com/calcium-vitamin-d-supplementation-in-osteoporosis
Singh, G., & Puckett, Y. (2020). Endometrial Hyperplasia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560693/
Aquifer Week Eight: Family Medicine 24
Student
United States University: FNP591 Common Illness Across the Lifespan
Professor
December 19, 2022
Case Analysis Tool Worksheet
Student’s Name: Student Case ID: Student_AQ_24
I. Epidemiology/Patient Profile
Amelia, a 4-week-old newborn is brought into the family medicine office by her mother who is concerned about her nightly fussiness for the past 10 days.
II. Prioritized Cues from History and PE.
Tier 1 Tier 2 Tier 3
Uncontrollable cries Patient’s mother tested negative for Group B Streptococcus (GBS) infection was negative Mother stopped smoking after she found out she was pregnant.
Amelia pulls her knees near her chest Father is a smoker Familial history on Father’s side of milk allergy.
Crying is more frequent at night Physical Examination is unremarkable.
She dribbles a small amount of breast milk after she has been fed. Normal weight gain in 4 weeks.
The baby cries continuously for 2 to 3 hours a day
Temperature was 37.5℃
No emesis or projectile vomiting.
Absence of a palpable “olive”.
PR is 132 beats per minute, RR is 42 breaths per minute, SpO2 is 98 % to 99%
90th percentile for height, 60th percentile for weight.
Breast fed every 3-4 hours during the day and 4-5 hours per night
Normal BM, color, consistency, and frequency
Ms. Arlington brought Amelia, a 4-week-old baby, to the family medicine office because she is concerned about her daily fussiness for the past two weeks. Ms. Arlington claims that she has also been crying uncontrollably for some time. Every evening, the crying begins and, depending on the volume, lasts between two and three hours. Also, she claims that nothing seems capable of soothing her during this moment of wailing. According to her mother, her urination and breastfeeding are typical. Her bowel habits are regular and normal. The mother of the patient also denies vomiting or fever. Amelia is gaining weight appropriately one pound since her two-week visit, and breast feeds very well.
III. Problem Statement
IV. Differential Diagnosis
Leading dx: Colic (Didişen et al., 2020)
History Finding(s) Physical Exam Finding(s)
Cries uncontrollably Temp 37.5℃, PR is 132 beats per minute, RR is 42 breaths per minute, SpO2 is 98 % to 99%
Amelia pulls her knees near her chest 90th percentile for height, 60th percentile for weight.
Crying is more frequent at night Absence of a palpable “olive”.
She dribbles a small amount of breast milk after she has been fed. Physical Examination is unremarkable.
The baby cries continuously for 2 to 3 hours a day Normal weight gain in 4 weeks.
No emesis or projectile vomiting. Great latch during breastfeeding assessment with audible swallow and gulping noises.
Breast fed every 3-4 hours during the day and 4-5 hours per night
Normal BM, color, consistency, and frequency
Alternative dx: Gastroesophageal Reflux Disease (Pados & Davitt, 2020)
History Finding(s) Physical Exam Finding(s)
Cries uncontrollably Temp 37.5℃, PR is 132 beats per minute, RR is 42 breaths per minute, SpO2 is 98 % to 99%
Amelia pulls her knees near her chest 90th percentile for height, 60th percentile for weight.
Crying is more frequent at night Absence of a palpable “olive”.
She dribbles a small amount of breast milk after she has been fed. Physical Examination is unremarkable.
The baby cries continuously for 2 to 3 hours a day Normal weight gain in 4 weeks.
No emesis or projectile vomiting. Great latch during breastfeeding assessment with audible swallow and gulping noises.
Breast fed every 3-4 hours during the day and 4-5 hours per night
Alternative dx: Intestinal obstruction of newborn (Jackson & Cruz, 2018)
History Finding(s) Physical Exam Finding(s)
Cries uncontrollably Temp 37.5℃, PR is 132 beats per minute, RR is 42 breaths per minute, SpO2 is 98 % to 99%
Amelia pulls her knees near her chest 90th percentile for height, 60th percentile for weight.
Crying is more frequent at night Absence of a palpable “olive”.
She dribbles a small amount of breast milk after she has been fed. Physical Examination is unremarkable.
The baby cries continuously for 2 to 3 hours a day Normal weight gain in 4 weeks.
No emesis or projectile vomiting. Great latch during breastfeeding assessment with audible swallow and gulping noises.
Breast fed every 3-4 hours during the day and 4-5 hours per night
Normal BM, color, consistency, and frequency
V. Explanation of Diagnostic Plan and Treatment Plan in prioritized order:
Diagnostic Plan Rationale
Thorough history and physical including reflexes May help in determining the etiology of fussiness, as there are psychological contributors (Turner & Palamountain, 2021)
Check stool for occult blood To rule out an allergy to cow’s milk (Cash & Glass, 2020)
Laboratory test and radiographic tests is not required Since Amelia is gaining weight normally and her physical examination is normal, there is no need for concern (Cash & Glass, 2020).
May consider Urinalysis To rule out UTI. The test is inexpensive, and many insurance policies may cover it (Cash & Glass, 2020).
Treatment Plan Rationale
If breastfeeding, consider 5 drops of lactobacillus reuteri dsm 17938. Lactobacillus reuteri administration to breastfed infants significantly reduces crying and fussiness in infants with colic (Sung et al., 2017).
Encourage Ms. Arlington to create a diary of crying and fussing spells. For Assessment and to help clinicians in identifying crying and fussiness patterns (Cash & Glass, 2020).
Encourage Ms. Arlington to take time away from Amelia. This will enable Ms. Arlington to recover the energy she needs to deal with Amelia’s wailing (Cash & Glass, 2020).
Educate the family about Colic Assure them that colic will subside with time, there is nothing physically wrong with the infant, and that they are doing an excellent job as parents. Examine symptoms of abdominal emergencies, such as fever, vomiting, diarrhea, and a painful abdomen (Turner & Palamountain, 2021).
Soothing techniques Experiment with what works, such as music, white noise, a pacifier, or a front-carrying baby carrier. The process of elimination will be well worth the effort (Turner & Palamountain, 2021).
Follow up office appointment Instruct the parents to return in two weeks so that Amelia’s weight and symptoms can be monitored (Turner & Palamountain, 2021).
Educate Ms. Arlington when to seek emergency care. Symptoms consisting of fever, pallor, sweating, vomiting, and diarrhea (Cash & Glass, 2020).
I have adhered to the honor system: Yes
Student’s signature
References
Alkilani, Y. G., & Apodaca-Ramos, I. (2021). Cervical polyps. PubMed. https://www.ncbi.nlm.nih.gov/books/NBK562185/
Braun, M. M., Overbeek-Wager, E. A., & Grumbo, R. J. (2016). Diagnosis and management of endometrial cancer. American Family Physician, 93(6), 468–474. https://www.aafp.org/pubs/afp/issues/2016/0315/p468.html
Cash, J. C., & Glass, C. A. (2020). Family practice guidelines (4th ed.). Springer Publishing Company, LLC.
Qaseem, A., Lin, J. S., Mustafa, R. A., Horwitch, C. A., & Wilt, T. J. (2019). Screening for breast cancer in average-risk women: a guidance statement from the American College of Physicians. Annals of internal medicine, 170(8), 547-560.
Rosen, H., Rosen, C., Schmader, K. E. & Mulder, J. E. (2022). Calcium and vitamin D supplementation in osteoporosis. UpToDate. https://www.uptodate.com/calcium-vitamin-d-supplementation-in-osteoporosis
Singh, G., & Puckett, Y. (2020). Endometrial Hyperplasia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560693/
Turner, T.L. & Palamountain, S. (2021). Infantile colic: Management and outcome. UpToDate. Retreived from https://www.uptodate.com/contents/infantile-colic-management-andoutcom
