Case Study

A 52 year old woman presented to the clinic for ongoing fatigue and weight loss during the last 6 weeks. She thinks she’s loss at least “10 pounds”. For the past week and a half she’s noted some progressing ‘muscle cramping’ tetany, as well as ‘tingling’ sensation around her mouth and lower extremities. She’s also noted some intermittent colicky abdominal pain. On your exam, you noted a positive Chvostek’s sign. PMH: 20 year history of Crohn’s disease. She also tells you that she is a practicing vegan.

  1. List the primary diagnosis and rational
  2. List at least 3 differential diagnosis with a brief rational
  3. Describe the pertinent history required to rule in or rule out
  4. Describe you physical exam findings or screening tools used
  5. Discuss the treatment plan for the patient in your case study using this format

Solution Preview

Case study

A 52-year-old woman presented to the clinic for ongoing fatigue and weight loss during the last 6 weeks. She thinks she’s a lost at least “10 pounds”. For the past week and a half, she’s noted some progressing ‘muscle cramping’ tetany, as well as ‘tingling’ sensation around her mouth and lower extremities. She’s also noted some intermittent colicky abdominal pain. On your exam, you noted a positive Chvostek’s sign. PMH: a 20-year history of Crohn’s disease. She also tells you that she is a practicing vegan.

Primary diagnosis and rational

The primary diagnosis for the patient is that she has hypocalcemia and hyperkalemia. This is attributed to the signs that are seen for the patients and the indication that the patient has presented since the patient has had the past history of muscle cramping and tetany with the issue of tingling sensation being a challenge that has arisen for the past for the patient. The condition that is aforementioned is an indication of the imbalance in the electrolytes that indicates dysfunction of the renal glands. As argued by Hudali and Takkar (2015), the imbalance in the level of electrolytes has resulted in the continuous rise in the chances of the patient having the aforementioned conditions….

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