Nicole Cantellops 10 cases

Dr. Daigle 2 cases written

February 17, 2020 8 hours
24 preceptorship hours

Day 1

Case 1: (acute visit)

CC/HPI: S.L. is a 72-year-old female with no complaints who presents to the office with a
request of clearing her for driving. Patient states having an accident while driving. She denied
losing consciousness and describes her symptoms as just being confused and disoriented while
driving. An MRI of her brain was read and showed scattered small white spots. Meds/All:
Patient is on Atorvastatin 20mg, Amphetamine 10mg, Ambien 5mg, Escitalopram 5mg and baby
Aspirin 81mg. PE: Vitals: BP- 146/73 mm Hg, HR- 88 bpm and BMI- 24.42. HEENT: PERRLA. CN
II-XII intact. Good muscle bulk and tone. No involuntary movements. Strength 5/5 in upper and
lower extremities. Pain, touch, proprioception, vibration intact in all 4 extremities and
stereognosis intact. A/P: The assessment is mild stroke. Patient was cleared for driving since
she didn’t lose consciousness with the stroke and remembered the entire event. No follow-up
was scheduled, just to call the doctor if this happened again.
What I learned: With this patient I learned to read a brain MRI and to appreciate how a stroke
looked like in a real patient.

Case 2: (follow up visit)

CC/HPI: J.J. a 71-year-old female presenting today for a Multiple Sclerosis follow-up. Patient
has an active MS with new lesions on her brain MRI. Drugs prescribed are not improving her
illness. She has no symptoms for now. Meds/All: Patient is on Cymbalta 30mg, Metformin
300mg 2 x day, Metoprolol 25mg 2 x day, Atorvastatin 20mg, Gemfibrozil 600mg, Insulin 40
units every evening, Xarelto 20mg, Vitamin D 5,000 units and Albuterol as needed. PE: Vitals:
BP- 154/72 mm Hg, HR- 48 bpm, BMI- 33.9. Patient presented alert, relaxed and cooperative.
She was sitting comfortably in the chair with no distress. No further physical examination was
done. A/P: The assessment is that the patient’s MS is not well controlled. The plan is to
prescribe her a new drug on the market for MS called Mavenclad. Patient was sent home to
read about this new treatment and schedule a follow-up for the next weeks to make a plan for
her treatment.
What I learned: This patient was a great case for learning because it was a rare one since
usually patients with active MS are between 20-40 years-old and this was a 71-year-old patient.
Nicole Cantellops 7 cases
Dr. Daigle 2 cases written
February 23, 2020 8 hours
24 preceptorship hours

Day 2

Case 3: (acute visit)

CC/HPI: J.P. is a 77-year-old male who presented to the office with a complaint of tiredness.
Patient reports having a car accident recently. Patient denies any loss of consciousness while
the event. Patient’s wife states watching his husband fall asleep every time during the day.
Patient reports going to the bathroom at night approximately 5 to 6 times. Meds/All: Patient is
on Crestor 10mg, Wellbutrin 300mg, Vitamin B12 1,000mcg, Vitamin D 5,000 units, Tylenol as
needed, stool softener as needed and Multivitamins once a day. PE: Vitals: BP- 106/62 mm Hg,
HR- 68 bpm, BMI- 22.92. CN II-XII intact. Good muscle bulk and tone. No involuntary
movements. Strength 5/5 in upper and lower extremities. Pain, touch, proprioception, vibration
intact in all 4 extremities and stereognosis intact. The MMSE cognitive testing was done and
patient got a score of 24/30. A/P: The assessment was sleep deprivation because of the
frequency in urination at night. Patient was referred to a urologist to check the prostate. Pt was
directed to return after seeing the urologist if no problem with his prostate was found, to
assess his problem of tiredness.
What I learned: With this patient I learned about the MMSE cognitive examination that I had
never saw being performed on a patient before.

Case 4: (follow up visit)

CC/HPI: P.H. is a 65-year-old female who presented to the office for a follow-up on her Multiple
Sclerosis illness. Patient requested a refill for her MS medications. Meds/All: Baclofen 20mg 3 x
day, Meloxicam 7.5mg 1 x day, Gabapentin 800mg 2 x day, Trazadone 50mg at bed time,
Vitamin D 5,000 units daily, Lisinopril 25mg 1 x day, Paxil 20mg 1 x day, Daypro 600mg 2 x day
and Fosamax 70mg once a week. PE: Vitals: BP- 126/71 mm Hg, HR- 59 bpm, RR- 16 bpm and
BMI- 26.95. CN II-XII intact. Good muscle bulk and tone. No involuntary movements. Decrease
sensation was noted on the left side of her face and on the right side her leg and arm. The
MMSE cognitive test was done with a score of 25/30. A/P: The assessment is that her
medications for MS are working with no recurrence of MS lesions. Patient had an indication for
the refill of her medications. The patient was scheduled for a follow-up of 6 months.
What I learned: With this patient I got the chance to perform her physical examination and
practice my clinical skills with a real patient that had decreased sensation on different parts of
her body.
Nicole Cantellops 6 cases
Dr. Daigle 4 cases written
February 24, 2020 8 hours
24 preceptorship hours

Day 3

Case #5: (acute visit)

CC/HPI: D.D. is a 65-year-old previously healthy female with a chief complain of a tremor on her
right hand that comes and goes. Patient states feeling tremors in her head, sometimes while
eating and also problems with her balance. Patient adds that sometimes feels pain while writing
but that she notices the tremors more while resting her hand. She denies any tremors in her
voice or trouble swallowing. She states being constipated all her life, also suffers from anxiety
and recently feels restless with approximately five hours of sleep. Meds/All: Patient is on
Escitalopram, Oxalate 10mg 1 x day, Ranitidine 300mg 1 x day and Vitamin D3 50,000 units
once weekly x 12 weeks. PE: Vitals: BP- 117/78 mm Hg, HR- 81 bpm. CN II-XII intact. Good
muscle bulk and tone; mild tremor noted on the right hand; strength is 5/5 in upper and lower
extremities. A/P: The assessment is exaggerated physiological tremor. Patient was
recommended to keep taking her medications and decrease her anxiety by increasing her sleep
hours and improve her living conditions. Pt was advised to call if any other changes occur.
What I learned: With this patient I learned about the different type of tremors and how to
differentiate parkinsonism from other types of tremors.

Case #6: (acute visit)

CC/HPI: S.F. is a 34-year-old female with a chief complain of migraines, fatigue and dizziness.
Patient describes her symptoms as daily headaches that start in the back of her neck and head.
She also reports pain in her left eye with nausea, light and sound sensitivity and pressure over
her eye. These episodes started at the end of July with periods of unbalance, dizziness when
bending over and pulsing/ringing sound on her ears when increasing physical activity. Her
symptoms started 3 per week but are now 1 per week since taking some medications
prescribed. Patient has a significant family history of migraines. Meds/All: Patient is on
propranolol every day and Imitrex taken as needed. PE: Vitals: BP- 113/78 mm Hg, HR- 64 bpm,
BMI: 25.07, Weight: 141 lbs., Height: 63 inches. HEENT: PERRLA. CN II-XII intact. Good muscle
bulk and tone. No involuntary movements. Strength 5/5 in upper and lower extremities. Pain,
touch, proprioception, vibration intact in all 4 extremities and stereognosis intact. A/P: The
assessment is migraines. Patient was recommended to keep going to her quiropractor and keep
taking propranolol. Pt was also prescribed Amitriptyline 25mg every night and educated about
the sedative side effect. Pt was to return if no improvement to increase the dose.
What I learned: With this patient I was able to take the history by myself and had the
opportunity to experience the patient-doctor interaction.
Case 7: (follow up visit)
CC/HPI: S.S. an 80-year-old female with a past medical history of recurrent night migraines for
the past two months presenting for a follow-up. Patient had a cervical spine MRI that showed
fused C6-C7 but with no physical symptoms on the patient. Patient states significant
improvement in her headaches and that they stopped occurring daily since she started going to
the quiropractor. Meds/All: Patient is on Metoprolol succinate 25mg 1 x day and Omeprazole
40mg as needed. Patient is allergic to penicillin (reaction: rash). PE: Vitals: BP- 179/77 mm Hg,
HR- 58, Weight- 160 lbs., Height- 5’2. Patient was alert, sitting comfortably with no distress. No
further physical examination was performed. A/P: The assessment is headaches from
musculoskeletal origin. Patient was advised to keep going to her quiropractor and follow-up
would be scheduled in 6 months.
What I learned: With this patient I was able to appreciate an abnormality in a spine MRI for the
first time.

Case #8: (new chronic illness)

CC/HPI: L.D. a 58-year-old female with a past medical history of hypothyroidism who presents
with a complain of seizures. Patient states having seizures throughout the day with rigidity in
the left side of her body. Patient also reports fatigue throughout the day. Brain MRI of patient
showed white spots that pointed towards MS diagnosis and was confirmed with a spine MRI
that showed more MS lesions. Meds/All: Patient is on a thyroid medicine 60mg, Keppra 500mg
2 x day and Multivitamins. PE: Vitals: BP- 120/79 mm Hg, HR- 80, RR- 10, Weight- 189 pounds.
CN II-XII intact. Good muscle bulk and tone. No involuntary movements. Strength 5/5 in upper
extremities but weakness was noticed on the right leg with some numbness. A/P: The
assessment was Multiple Sclerosis. Patient was sent home with four treatments to read on.
Patient was given a couple of weeks to call with a decision of her treatment and then a follow-
up would be scheduled to begin treatment.
What I learned: With this patient I learned how to give the diagnosis of an illness for the first
time to a patient. This was a big lesson on how to give bad news to a patient and her family.