Well Visit Skin Findings

Hypothyroidism & Fatigue

A 45 year old woman with a 10 year history of hypothyroidism presents for follow up care. She's been taking levothyroxine 100 micrograms per day with excellent adherence. Stating "I take the medicine every morning on an empty stomach with a big glass of water.” She states she's generally feeling well, but notices increased fatigue over the past four months, which she attributes to the stress of starting her graduate studies while working full time. The results of today's laboratory testing include the following:

TSH is 2.3, the norm being .4 to 4, pre T4 15 with norm being 10 to 27.

The next step in her care is to:

A. continue on the same levothyroxine dose and obtain a repeat TSH in one year.

B. increase the levothyroxine dose by 25 micrograms per day and repeated TSH in one month.

C. increase the levothyroxine dose by 25 micrograms per day and repeated TSH in two months.

D. Repeat the TSH and free T4 today and provide counseling about taking the medication with breakfast.
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Laboratory findings in pregnancy

A 28-year-old woman presents with new onset worsening fatigue, present for approximately the last month. She is 28 weeks pregnant with her second child, has a 1.5-year-old healthy child at home, says she remembers being tired towards the end of her pregnancy with her first child, but states, “This is worse than with my last pregnancy”. She denies vaginal bleeding or discharge, abdominal pain, or other concerning issues, is sleeping about 7 hours per night, and has adequate access to nutritious food. She is not taking a prenatal vitamin, reporting, “I kept throwing up every time I took one.” During early pregnancy. PHQ-9 screening tool results are without concern.

Labs results are as follows.

Hemoglobin 9.2g per dl (NL=12-14)

Hct=27% (NL=36-42%)

Total RBC= 2.9 million (3.9 to 5.2 million cells per microliter (million/µL)

MCV 75 FL (NL=80-98)

MCH 22 PG (NL=27-33)

RDW 18% (NL=11.5-15%)

These results are most consistent with:

A. Pregnancy related hemodilution.
B. Folic acid deficiency anemia
C. Iron deficiency anemia.
D. Beta thalassemia minor.
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YouTube: https://www.youtube.com/watch?v=3bvYICmJ1N4&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=69

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Sinus infection treatment

A 35 year old presents with chief complaint of “my sinus infection is not getting better”, with continued nasal and sinus congestion, yellow to white nasal discharge, and a feeling of sinus pressure particularly when he bends over. He denies sore throat headache, and GI symptoms, and previously reported fever prior to treatment is now resolved. The EMR documentation notes a prescription for dose-appropriate amoxicillin with clavulanate written 2 1/2 days ago when seen for a sick visit. Patient states he has taken the antibiotic as advised, staring the medicine on the day of his sick visit, and has not missed any doses. Physical exam reveals a no acute distress, mild tenderness to sinus palpation, and no fever. The next most appropriate step in this patient's treatment plan is to:

A. Advise the patient to continue his current course of therapy.
B. Switch his antimicrobial to moxifloxacin.
C. Order a CT of the sinuses.
D. Perform a posterior pharyngeal culture and sensitivity.
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YouTube: https://www.youtube.com/watch?v=U328N8YjNs8&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=68

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Viral gastroenteritis

Joseph is a 14 year-old, generally well and up-to-date with health maintenance, who presents for a sick visit, stating, “My stomach has not been right for about 4 days. The illness began with a 36 h hx of gradual onset nausea, vomiting and loose stools, reporting “I’m not sure how many times I threw up or had diarrhea.” He last vomited about 24 h ago, last stool was around 4 h ago, reported as yellow-brown in color, small volume and without blood. He has been tolerating clear liquids for the past 24 h and voided a small amount around 2 h ago. He feels “a little bit hungry but I am afraid to eat or I might throw up again. I still feel a little bit sick to my stomach.” Joesph reports that he is on the wresting team at his high school and that, “For the past week, one guy after another got this same thing.” VS are within normal limits and denies dizziness with position change from supine to sit or stand. His mucous membranes are slightly dry, with intact skin turgor, and mild diffuse abdominal tenderness without rebound. With a working diagnosis of viral gastroenteritis, which of the two following clinical actions should be taken?

A. Obtain stool for culture and sensitivity.
B. Order a chem panel.
C. Provide information about a slowly progressive diet as tolerated.
D. Prescribe an antiemetic.
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YouTube: https://www.youtube.com/watch?v=_P1Ff1fWzJI&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=67

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Differential Diagnosis - N&V in Teen

Joseph is a 14 year-old, generally well and up-to-date with health maintenance, who presents for a sick with a 36 h hx of gradual onset nausea, vomiting and loose stools, reporting “I’m not sure how many times I threw up or had diarrhea.” He last vomited about 4 h ago, last stool was around 2 h ago, reported as yellow brown in color, small volume and without blood. He has been tolerating a sips of clear liquids for the past 3 h and voided a small amount around 2 h ago. Joesph reports that he is on the wresting team at his high school and that, “For the past week, one guy after another got this same thing.” VS are within normal limits and his mucous membranes are slightly dry. The most likely cause of Joseph’s clinical condition is:

A. Staphylococcal food poisoning
B. Clostridium difficile (C. diff) enteritis
C. Viral gastroenteritis
D. Gastric ulcer
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YouTube: https://www.youtube.com/watch?v=_n_b1BfwfUc&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=66

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