Now, assume that you sent your patient for labs and she returns the following day, as instructed, to review the results.

CBC with differential

WBC                                        8.6 x10E3/uL
RBC                                         4.44 x 10E6/uL
Hemoglobin                           14.0 g/dL
Hematocrit                             41.2%
MCV                                         93fL
MCH                                        31.5 pg
MCHC                                      34.0 g/dL
RDW                                        13%
Platelet                                    241 x 10E3/uL
Neutrophils %                        67%
Lymphocytes %                      22%
Monocytes %                          8%
Eosinophils %                         3%
Basophils %                             0%
Absolute Neutrophils            5.7 x 10E3/uL
… Lymphocytes          1.9 x 10E3/uL
Absolute Monocytes              0.7 x 10E3/uL
Eosinophils Absolute            0.3 x 10E3/uL
Basophile Absolute                0.0 x 10E3/uL
Immature Grans %                0%
Absolute Immature Grans   0.0 x 10E3/uL

TSH with Reflex to FT4
TSH 6.770 uIU/mL
FT4 0.62 ng/dL

PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago)

1.What is your primary diagnosis for this patient as the cause for the CC of fatigue? (support your decision for your diagnosis with pertinent positives and negatives from the case)
2. Identify the corresponding ICD-10 code.
3. Provide a treatment plan for this patient’s primary diagnosis which includes:

o Medication*
o .Any additional testing necessary for this particular diagnosis*
o Patient education*
o Referral

4. Provide an active problem list for this patient based on the information given in the case.
5. Are there any changes that you would make to the patient’s overall plan at this time? Must provide an evidence-based medicine (EBM) argument to support any treatments or testing decisions.
6. Provide an appropriate follow-up plan (include any additional testing that you feel is necessary and include an EBM argument).

*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an EBM argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.