Please respond to at least 2 of your peer’s posts. To ensure that your responses are substantive, use at least two of these prompts:
- Do you agree with your peers’ assessment?
- Take an opposing view to a peer and present a logical argument supporting an alternate opinion.
- Share your thoughts on how you support their opinion and explain why.
- Present new references that support your opinions.
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with citations and references in APA format.
CC: Something is wrong with me
HPI: 48 y/o woman presenting today for fatigue, concentration issues, appitite changes, constipation and weight over past 6 weeks. Pt states that she feels down in the dumps and does not enjoy the usual things she likes. Pt also reports having irregular periods.
ROS:
General: reports weight gain, fatigue, and appetite changes
HEENT: Denies headaches, difficulty sleeping and troubles swallowing, and vision changes.
Cardiovascular: Denies chest pain, chest tightness, palpations and inablilty to lie flat
Respiratory: Denies shortness if breath, troubles breathing and cough.
Gastrointestinal: Reports appetite changes and weight gain
Genitourinary: Denies pain, urgency , discharge and frequency
GYN: Reports irregular periods
MSK: Denies joint pain, swelling.
Skin: Reports dry skin. Denies lesions, lumps and rash.
Neurological: Denies dizziness, weakness
Psychological: Reports difficulty concentrating, mood changes.
Hematologic: Denies abnormal bleeding or bruising
Endocrine: Reports weight gain and fatigue.
Objective
Physical Examination
General: Alert, oriented x 4. Sluggish gait
HEENT: Normal speech, tone. Face symetry noted.
Cardiovascular: No mumurs, clicks or rubs. Peripheral pulse present. No edema. Normal color.
Respirtory: Normal rate. Symetric rise and fall. Clear to asultation.
Gastroinstestinal: Non tender to palpation. Bowel sounds present. Soft, non distended.
Genitalurinary: Bladder non tender.
GYN: Cervix non tender.
MSK: Sluggish gait.
Skin: Dry skin, briitle nails and thinning hair.
Neurological: Answers questions slowly
Psychological: Effect blunt.
This patient is reporting changes in mood. I would ask this patient about recent changes in her life, including stressors. I would also ask this patient about feelings regarding harning herself or others. I would ask this patient about her last normal cycle. My obtaining of information would include her sexual history, her family hx, and social hx. I would also request a complete list of medications she is taking including vitamins.
Differential diagnosis:
Differiental diagnosis for this patient would include Perimenopausal depression. The supporting evidence for this daignosis include low energy, weight pain, problems with memory, irritability, and problems with concentration (Delamater & Santoro, 2018). The diagnosis mild depression could be supported by the reports of fatigue, changes in appetite, lack of concenration, wieight gain, and not enjoying activities that she normally enjoys (Cherney, 2017). Another fitting diagnosis for this patient includes Hypothyriodism. This patient suffers from may of the classic symptoms of hypothyriodism such as fatigue, dry hair, brittle nails, weight gain and slow movements (Chaker et al., 2017).
Assessement/Plan
Perimenopausal Depression F32.89
Diagnosis: CBC, TSH, CMP, FSH, LH and a UA. Transvaginal ultrasound. (Delamater & Santoro, 2018)
Therapeutics: The medication choice for this would medications that manage both depressions and perimenopausal symptoms. SSRI or SNRI would be likely option for this patient. Depending upon the results of the blood testing an HRT would likely help manage this patient symptoms (Delamater & Santoro, 2018).
Education: Discussion regarding the side effects of meducations used for depressions would be done. Education would also be focused around side effects of medications that support perimenopausal symptoms. Pt would. be aware that if she experiences s/s of suidicdal ideation she should call 911 immediately. Pt would also be educated on the importance of keeping all scheduled appointments to monitor progress and the need for a mental health questionnaire to be done to assist with evaluating progress (Cherney, 2017).
Consultation/ Collaboration: This patient may benefit from a nutritionist consult for weight gain. A Psy referral may also be benefical in the event the medications and plan of treatment do not work.
With the above information, construct the subjective and objective data in a SOAP Note format.
Subjective: KP is a 48 yo female who presents with a 6-week history of fatigue, concentration difficulties, appetite changes, constipation, and weight gain, sleepiness. She endorses a somewhat depressed mood, decreased interest in her work (substitute teacher) which she usually enjoys. She also notes that her menstrual periods have been irregular. She denies any past behavioral health concerns or treatment. She denies any thoughts of self-harm.
Objective:
General: 20 lb weight gain since last year.
Derm: Dry skin, brittle nails.
MSK: Gait is sluggish
Neuro; responses are appropriate but slow. Her speech is clear.
Psych: A&O. Affect is blunted, but expresses appropriate goals.
Is there any other information that you would obtain to assist you in determining treatment options?
Additional information which I will need centers around possible differential diagnoses I am considering after reviewing the initial vignette. Initially questions for the patient about thyroid and any autoimmune history are relevant, including radiation exposure to the neck, swelling in the anterior neck, sore throat. Objectively I would test her reflexes, as a blunted reflex response is consistent with hypothyroidism (Patil et al., 2022). A TSH, T3, and T4 will need to be ordered to determine this diagnosis. Because hypothyroidism is related to lipid panel abnormalities, this will be ordered as well (Patil et al., 2022).
Our patient mentioned irregular menstrual cycles. Because of her age, I would think about perimenopause. I will need to know specifically if her menstrual periods are more or less frequent, and how heavy her flow is. If her cycles are short, or if the duration is long, she could also be exhibiting some symptoms of iron deficiency anemia (Delamater & Santoro, 2018). Perimenopause is a specific risk factor for iron deficiency anemia and can negatively affect quality of life (Firquet et al., 2017). Additional symptoms to inquire about include hot flashes and vaginal symptoms (Delamater & Santoro, 2018). She has already endorsed issues with sleep and mood (Delamater & Santoro, 2018). A complete blood count will be ordered, and if abnormal, iron studies are appropriate (Delamater & Santoro, 2018).
Our patient has mentioned that she has appetite changes, and I would like to elaborate on that a little further. I will need to clarify if she follows any restrictive diets, if she has significantly decreased or increased her intake, or cut out any categories of foods, or has a history of any malabsorption syndromes such as Celiac disease or bariatric surgery (Ankar & Kumar, 2022). Vitamin B12 deficiency can lead to anemia, which could cause fatigue, pallor, tongue inflammation, diarrhea, and psychiatric complaints (Ankar & Kumar, 2022). While this is not at the top of my differential list, if she does indicate she follows a restrictive diet such as veganism, a CBC with differential and folate level would be appropriate (Ankar & Kumar, 2022).
Because our patient has nonspecific symptoms, autoimmune etiology should be considered. This could include the top differential of thyroid disease, but can also include disorders such as rheumatoid arthritis or Sjogren’s syndrome among others (Angum et al., 2020). Rheumatoid arthritis is most common in women around the age of menopause, which could describe our patient (Angum et al., 2020). I would like to ask our patient about joint pains, fevers, dry eyes, dry mouth, rashes, and her pregnancy history (Angum et al., 2020).
Some of our patient’s symptoms could be consistent with depression. Depression is correlated with changes in sleep, feelings of sadness, loss of interest or pleasure in things, changes in ability to get things done, changes in weight, inability to concentrate, feelings of guilt, and cognitive changes (Chand & Arif, 2023). I would like to complete a PHQ-9 questionnaire with her and ask her about feelings of sadness, if any (Chand & Arif, 2023). No further diagnostic testing would be done for this diagnosis. Few lab tests are done for depression, however thyroid levels and vitamin D levels are often checked to rule out underlying cause (Chand & Arif, 2023).
Discuss the top three differential diagnoses.
- Hypothyroidism
Hypothyroidism is generally primary or secondary, with autoimmune hypothyroidism being the most common cause in the United States (Patil et al., 2022). Anti TPO antibodies can be checked with a blood test to rule out Hashimoto’s thyroiditis (Patil et al., 2022). Our patient has many symptoms of thyroid disorder including fatigue, skin dryness, constipation, sleep and menstrual changes along with weight gain (Patil et al., 2022).
- Perimenopause
Perimenopausal symptoms often start years prior to the onset of menopause (Delamater & Santoro, 2018). Our patient has not mentioned hot flashes, which are common in perimenopause, however she did changes in sleep, mood, abnormal menstrual bleeding (Delamater & Santoro, 2018). Depressive symptoms in women who have no prior history of depression can be related to hormonal changes of menopause (Delamater & Santoro, 2018).
- Depression
Depressive disorders are usually identified through the history with the patient. It is more common in women than in men. Her personal circumstances including major life stressors should be explored (Chand & Arif, 2023). Finally, a PHQ-9 provides screening questions to provide an objective measure (Chand & Arif, 2023).
What initial diagnostics would you order?
As discussed in question two, initial diagnostics will include TSH, free T3, T4 and anti-TPO antibodies. Additional labs for the workup of hypothyroidism and the other differential diagnoses will include comprehensive metabolic panel, CBC, and lipid panel (Patil et al., 2022). A vitamin D level will be checked as well (Chand & Arif, 2023).
