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Mr. T.G., age 65, is a well-established patient in your practice. He presents to the office complaining of lightheadedness when he stands up. The patient also states he has had a change in his stool over the past week and with some abdominal cramping. He denies fever, chills, or vomiting. The patient has a medical history of HTN, hyperlipidemia, atrial fibrillation for which he is taking warfarin and arthritis in his right knee, which he controls with an over the counter analgesic. He denies drinking alcohol and quit smoking cigarettes 20 years ago. His physical exam is the following:

BP: 136/76  HR: 108. RR: 22  T: 98.9  saO2: 98%
HEENT: pale conjunctiva bilaterally.
CV: RRR (-) murmurs/bruits/jvd, (+) tachycardia
Resp: SOB on mild extertion
Abdomen: Hyperactive BS all quadrants, (-) tenderness on palpation
Ext: Moves all extremities, (-) edema or swelling, pulses intact
Neuro: PERLA, mildly off-balance when standing or changing positions
Skin: Observable pallor
From the case described above, what are the most important ROS questions for you (the APN) to ask this patient and why? Remember this is a focused case, not a physical.

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Part 1
Are there more questions to be asked of the HPI?
Based on the scenario for this TSD, what labs or tests need to be ordered? List all that apply to this case
What is your preliminary diagnosis?  What are your DDX?
What evidence has brought you to this conclusion?

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Part2
The patient returns to your office the next morning. You review the CBC report with him. 
WBC 3.4 (D)
RBC 3.01 (D)
HGB 10.8 (D)
HCT 31.1 (D)
MCV 76.3 (D)
MCH 32.9 (D)
MCHC 29.7 (D)
RDW 19.1 (I)
PLATELET 213 (N)
D= decreased. I= increased N= normal

What are the next steps? 

What additional lab tests do you order?
Any consults required? 

Is this a critical case requiring the ED services today or can this be treated as an outpatient?
How do you treat this patient? 

What type of education do you need to provide? 

When should he follow up with you?

SCIENCE
HEALTH SCIENCE
NURSING
PN 3

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