case study

1. Maria is a 35 y/o female who is complaining of frequent vaginal yeast infections. She has had 4 in the last 6 months, and they have been treated with topical and oral antifungal medications which have initially worked, but the infections recur within 1-2 weeks. Maria reports increased thirst and urination for the last two to three months. Maria is an office manager in a bookstore who works full-time and has 4 children aged 5, 7, 10, and 12, who live with her 80% of the time. She has been divorced x 3 years and is struggling to make ends meet and reports she and her children frequently eat fast food because of the low cost and time constraints. Maria’s vital signs are 136/88, 98.8, 16, 80, Ht 5’3”, Wt 187 lbs,  
    
2. Tim is a 22 y/o male who is complaining of lethargy, cold sensitivity, weight gain of 10 lbs over the last 3 months with an unnoticeable change in appetite, brain fog, constipation, and muscle weakness that he feels has become progressively more noticeable over the last several months. Tim is a heterosexual, single, full-time college student and works part-time at a coffee shop. His last annual physical examination was 2 years ago and was WNL. His current vital signs are 110/70, 62, 98.6, 12, Ht 5’9” Wt 190 lbs.  

Case Study Chosen: (List what case you have chosen)

Demographics: Age/Gender

SUBJECTIVE

• CC:

• HPI: (As listed from Case Study Information)
• Subjective: (What questions will you ask? Must be listed by System, ONLY as it

pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe
unless pertinent).

OBJECTIVE

General:

• VS BP, HR, RR, Weight, Height, BMI
• Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief

Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)
• POC Testing (any Point of Care (POC) testing specifically performed in the office):

What tests (if any) did you perform during the visit (urine dip, rapid strep, urine
pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.

ASSESSMENT

• Working Diagnosis: (Must include ICD 10)
• Differential Diagnosis:

PLAN

• Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you
will be ordering for your patient. Remember the importance of appropriate resource
utilization. Remember you are managing this patient in the CLINIC setting, NOT THE
HOSPITAL.

• Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of
medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT
only list drug class. Should follow evidence-based guidelines.

• Referrals: If Applicable

• Education:
• Health maintenance:
• RTC:

Diagnosis Signs/Symptoms Gold Standard
Diagnostics

Gold Standard
Treatment

Hyperthyroidism

Grave’s Disease

Hypothyroidism

Hoshimoto’s
Thyroiditis

Addison’s Disease

Cushing’s

Diabetes Mellitus
Type 1

Diabetes Mellitus
Type 2

Hyperprolactinemia