-
- QUESTION
-
Week 6 assign
Requirements:
- Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information.
- Provide a differential diagnosis (minimum of 3) which might explain the patient's chief complaint along with a brief statement of pathophysiology for each.
- Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
- Rank the differential in order of most likely to least likely.
- Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBM evidence.
Case Study
Date of visit: November 7, 2017
A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Upon further questioning you discover the following subjective information regarding the chief complaint.
History of Present Illness
Onset
"about 2-3 months"
Location
Generalized
Duration
Constant
Characteristics
Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well rested. "No energy to do anything I normally can do"
Aggravating factors
Exertion
Relieving factors
None identified
Treatments
None
Severity
Denies pain; missed 1 day of work 2 weeks ago because "couldn't get out of bed"
Review of Systems (ROS)
Constitutional
Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months ago.
Eyes
No visual changes or diploplia
ENT
Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea.
Neck
Denies lymph node tenderness or swelling
Chest
Denies cough, SOB, DOE or wheezing
Heart
Denies chest pain
Abdomen
Denies N/V/D. + Constipation
Endocrine
Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.
Skin
No changes in skin, hair or nails
Psych
Reports worsening of depressive symptoms but thinks it is because she is so "unproductive" lately and tired all of the time. -Suicidal or homicidal thoughts. Sleeping 8-9hrs per night (no changes), but not feeling rested.
Musculoskeletal
Generalized weakness and intermittent muscles cramping in calves
History
Medications
Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU.
PMH
HTN, Depression, Postmenopausal status
PSH
Tonsillectomy
Allergies
Iodine dyes
Social
Married; Works full time as office manager of an internal medicine office; 2 kids (grown)
Habits
Denies cigarettes or drug use. +Occasional glass of wine (1-2 per month).
FH
Maternal GM & GF deceased with CHF, T2DM and HTN;
Mother alive (age 82) +HTN, +Hyperlipidemia, +T2DM;
Father alive (age 84) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p CABG 2 years ago). Also had +CVA at time of CABG (work-up revealed +DVT and +PFO; remains anticoagulated);
Oldest child (26) with seasonal allergies
Youngest child (24) with Bipolar depression and ADHD, and anxiety
Physical exam reveals the following:
Physical Exam
Constitutional
Middle aged Caucasian female alert, oriented and cooperative
VS
Temp-98.2, P-74, R-16, BP 146/95, Height: 5'7", Weight: 180 pounds
Head
Normocephalic, atraumatic
Eyes
PERRLA
Ears
Tympanic membranes gray and intact with light reflex noted.
Nose
Nares patent. Nasal turbinates without swelling. Nasal drainage is clear.
Throat
Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities.
Neck
Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
Cardiopulmonary
Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. No pedal edema
Abdomen
Soft, non-tender. BS active
Skin
Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Psych
Mood pleasant and appropriate.
Musculoskeletal
Strength full throughout
Neuro
DTRs 2+ at biceps, 1+ at knees and ankles
**To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric.
DISCUSSION CONTENT
Category
Points
%
1. Description
Application of Course Knowledge
15
30%
1. A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND
2. Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND
3. A brief statement of pathophysiology is included for each diagnosis; AND
4. Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND
5. The differential is ranked in order from most likely to least likely; AND
6. Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND
7. Testing decisions are well supported with EBM arguments that are in-line with the clinical scenario and appropriate for the primary care setting
(7 critical elements)
Support from Evidence-Based Practice (EBP)
15
30%
1. Discussion post is supported with appropriate, scholarly sources; AND
2. Sources are published within the last 5 years (unless it is the most current CPG); AND
3. Reference list is provided and in-text citations match; AND
4. All testing decisions are fully supported with an appropriate EBM argument
(4 critical elements)
Interactive Dialogue
10
20%
1. Student provides a substantive* response to at least one topic-related post of a peer; AND
2. Evidence from appropriate scholarly sources are included; AND
3. Reference list is provided and in-text citations match; AND
4. Student responds to all direct faculty questions
(*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response
(4 critical elements)
Total CONTENT Points= 40 pts
DISCUSSION FORMAT
Category
Points
%
Description
Organization
5
10%
1. Case study response is presented in a logical format, AND
2. Responses are in sequence with the numbered questions AND
3. The case study response is understandable and easy to follow AND
4. All responses are relevant to the case topic
(4 critical elements)
Grammar, Syntax, Spelling & Punctuation
5
10%
Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors*
Total FORMAT Points= 10 pts
DISCUSSION TOTAL= 50 pts
**To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric.
Search entries or author Filter replies by unreadUnread Collapse replies Expand replies
Replies are only visible to those who have posted at least one reply.
| Subject | Nursing | Pages | 4 | Style | APA |
|---|
Answer
Week 6 Assignment
Part 1: History and Physical Findings
A Caucasian female aged 56 years with a hx of depression and HTN presented with a CC of fatigue that is constantly generalized. The patient indicates that the fatigue symptoms were first experienced 2-3 months ago and have progressed over the time. The patient records that she lacks the drive to do her normal daily activities and is always feeling tired. Moreover, she mentions that she gets at least 8 hours of sleep but never feel well rested. Also, the fatigue symptoms recorded by the patient worsens with exertion. The fatigue has prompted the patient to miss work after she found it difficult to get out of bed. The family hx records instances of heart disease and T2MD. The patient occasionally takes wine and tobacco. Her medication history indicates that she is on Prozac 20mg, Calcium, multivitamins and Vit D3. Additionally, the female is allergic to Iodine dyes, recorded a 5lb weight increase in the past 6 months, has a cold intolerance, shows signs of constipation, intermittent BLE cramping, and depression. She records negative changes on nail, skin, and hair and no signs of OSA.
The physical examination process revealed that the patient’s thyroid had no palpable masses and was firm and small in size. Unremarkable findings were established for the HEENT and the abdomen. The patient’s skin was dry, her hair was coarse and thick, but the nails did not show any abnormality signs. The patient’s strength of extremities was also desirable.
Differential Diagnosis
Major Depressive Disorder
Major depressive disorder arises from neurotransmitter’s deficiency such as norepinephrine and serotonin present in the brain (Yin et al., 2018). Fatigue is one of the common symptoms related with the reduction in the levels of the hormones.
Chronic Fatigue Syndrome
This is a situation featured by profound sleep abnormalities and fatigue which becomes worse by exertion. Fatigue which is experienced for more than 6 months is the primary symptom for chronic fatigue syndrome (Yang et al., 2019).
Hypothyroidism
When the thyroid hormone fails to produce enough thyroid hormones, the major organs of the body are affected with fatigue being one of the primary symptoms (Ahi et al., 2019).
Analysis
Chronic Fatigue Syndrome: Patient shows positive signs of profound fatigue symptoms which has lasted approximately 3 months and does not get better with rest. However, she does not show signs of dizziness when standing or sitting.
Major depressive Disorder: Patient shows positive signs of a depressed mood, fatigue and increased weight. However, she does not record signs of suicidal idea or sleep deprivation.
Hypothyroidism: Patient shows positive signs of constipation, fatigue, general weakness, dry skin, depression, cold intolerance, and muscle cramps. However, she does not show signs of thyroid enlargement during palpitations, loss of hair or brittle nails.
Ranking
Hypothyroidism (Most Likely)
Chronic Fatigue Syndrome (Likely)
Major Depressive Disorder (Least Likely)
Testing and Decision
The patient should undergo through blood testing to confirm or disprove hypothyroidism because this is the most likely diagnosis. Uyar et al. (2016) state that conducting a blood test to test the level of hormones is necessary for the patient since it determines if the level of thyroid hormones is within the suitable range for the patient (Ahi et al., 2019). A thyroid function test will be specifically recommended for the patient since it will provide an indication of the thyroxine and thyroid stimulating hormone present in the blood (Ahi et al., 2019). A low level of the hormone in the blood will prove that the patient is suffering from hypothyroidism.
Part 2
Primary Diagnosis
The patient’s primary diagnosis is hypothyroidism. Notably, the patient shows positive signs of constipation, fatigue, general weakness, dry skin, depression, cold intolerance, and muscle cramps. However, she does not show signs of thyroid enlargement during palpitations, loss of hair or brittle nails.
ICD Code
The ICD 10 Code for hypothyroidism is E03.9.
Treatment Plan
The standard treatment implemented for the hypothyroidism involves the daily usage of the synthetic thyroid hormone levothyroxine. The oral medication is effective in restoring the levels of hormones, thus reversing the hypothyroidism signs and symptoms.
Test such as the Thyroid function tests should be ordered for further screening. This will include further blood tests such as T3, T4 and T3RU (Yin et all., 2018). This will be effective in diagnosing hypothyroidism. Patient education is necessary in the management of the condition since it will inform the patient about the benefits of factors such as drug adherence. Looking at the referral guidelines for hypothyroidism, it is evident that the patient should first undergo through test such as TSH and have clinical notes and lab records documenting even growth chart.
Active Problem List
- Constipation
- Fatigue
- General weakness
- Dry skin
- Depression
- Cold intolerance
- Muscle cramps
Proposed Changes
I would include synthetic thyroid hormone levothyroxine in the patient’s treatment plan. The focus is to ensure that the patient’s thyroid hormones is increased to the normal levels (Park & Ju, 2019).
Follow Up Plan
The follow up plan will take place after a period of 6 weeks. This is based on the fact that Levothyroxine is related with a 1-week plasma half-life. A steady state is attained after a period of 6 weeks after this medication is included within the patient’s regimen (Park & Ju, 2019). Subsequently, the patient will be required to undertake a blood test once every year to ensure that the TSH level remains at a value less than 4 (Park & Ju, 2019). Hypothyroidism requires a lifelong monitoring.
art skills.
References
Ahi, S., Amouzegar, A., Gharibzadeh, S., Delshad, H., Tohidi, M., & Azizi, F. (2019). Correction: Trend of lipid and thyroid function tests in adults without overt thyroid diseases: A cohort from tehran thyroid study. PLoS One, 14(7) doi:http://dx.doi.org/10.1371/journal.pone.0220324
Park, E. S., & Ju, Y. Y. (2019). Factors associated with permanent hypothyroidism in infants with congenital hypothyroidism. BMC Pediatrics, 19, 1-7. doi:http://dx.doi.org/10.1186/s12887-019-1833-8
Uyar, B., Solak, A., Saklamaz, A., Akyildiz, M., Genç, B., & Gökduman, A. (2016). Effects of isotretinoin on the thyroid gland and thyroid function tests in acne patients: A preliminary study. Indian Journal of Dermatology, Venereology and Leprology, 82(5) doi:http://dx.doi.org/10.4103/0378-6323.182794
Yang, M., Keller, S., & Lin, J. S. (2019). Psychometric properties of the fatigue short form 7a among adults with myalgic encephalomyelitis/chronic fatigue syndrome. Quality of Life Research, 28(12), 3375-3384. doi:http://dx.doi.org/10.1007/s11136-019-02289-4
Yin, Z., Chang, M., Wei, S., Jiang, X., Zhou, Y., Cui, L., . . . Tang, Y. (2018). Decreased functional connectivity in insular subregions in depressive episodes of bipolar disorder and major depressive disorder. Frontiers in Neuroscience, doi:http://dx.doi.org/10.3389/fnins.2018.00842