NR511 Week 6 Case Study Discussion

A 56-year-old Caucasian female presents to the office today with complaints of generalized fatigue for the last 2-3 months and worsens on exertion, thus causing progressive worsening since onset. She reports feeling tired all of the time, sleep 8hrs per night, but does not feel well- rested. She stated that she has no energy to do the things she usually does and reported missing “1 day of work 2 weeks ago” because she could not get out of bed. She denies pain and reported no treatments or relieving factors. ROS: Constitutional: Denies fever, chills, or recent illnesses. She reported a 5lb weight gain since her last office visit 6 months ago. HEENT: HEENT: Negative. No visual changes or diplopia. Denies any ear pain, coryza, rhinorrhea, or ST. She reported having a tonsillectomy as a child. Denies snoring or a history of sleep apnea. Denies any lymph node tenderness or swelling. Respiratory: Denies cough, SOB, DOE or wheezing CV: Denies chest pain GI: Denies N/V/D. + Constipation GU: Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs. Skin: Negative. No changes in skin, hair, or nails Psych: Reports worsening of depressive symptoms but thinks it might be contributed to being “unproductive” and tired all of the time. Negative for SI/HI. No changes in sleep pattern, gets 8- 9hrs of sleep per night but not feeling rested. Musculoskeletal: Reports generalized weakness and intermittent muscles cramping in calves Allergies: Iodine dyes Medications hx: Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg & Vit D3 400IU. Medical history: HTN, Depression, Postmenopausal status PSH: Tonsillectomy Family hx: Maternal GM & GF deceased with CHF, T2DM & HTN; Mother alive (82-y.o) +HTN, +hyperlipidemia, +T2DM; Father alive (84-y.o.) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p +DVT & +PFO; remains anticoagulated); Oldest child (26 y.o.) has seasonal allergies, youngest child (24 y.o.) has bipolar depression and ADHD & anxiety Social hx: Employed F/T, she is married with 2 adult children, denies smoking cigarettes or illicit drug use. Drinks wine (1-2 glasses p/month) socially. Physical Examination Constitutional: Middle-aged, caucasian female AxO and cooperative Vital Signs: BP 146/95, Temp 98.2, P 74, RR 16, Hgt 5’7”, Wgt 180lbs HEENT: Head normocephalic, atraumatic. Eyes PERRLA. The tympanic membranes are gray, intact with light reflex noted. Nares patent; turbinates no bogginess, no swelling, nasal drainage is clear. Oropharynx moist, no lesions or exudate. Bilateral tonsils surgically removed. No dental caries noted. Neck supple, thyroid small, firm, & midline no palpable masses; no lymphadenopathy noted. Cardiopulmonary: Lungs clear b/l with auscultation respirations unlabored and S1 and S2 noted and no M/G/R. No pedal edema. GI: Soft, non-tender, BS active x 4 quad Skin: Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration Psych: Mood pleasant and appropriate. Msk: Normal strength throughout Neurological: DTRs 2+ at biceps, 1+ at knees and ankles DDx: Hypothyroidism: In hypothyroidism, the thyroid gland (TH) does not produce enough thyroid hormome. TH is “regulated by TRH through a negative-feedback loop that involves the anterior pituitary and hypothalamus” (McCance, Huether, Brashers, & Rote, 2019). Disruption of the TH will affect bodily functions such as how the body regulates temperature, heart rate, and all aspects of metabolism (McCance, Huether, Brashers, & Rote, 2019). The patient will report cold intolerance, constipation, weight gain, hoarseness, enlarged thyroid, decrease pulse rate, coarse dry hair, symptoms of depression, and fatigue (Dains, Baumann, & Scheibel, 2020, p.15). Pertinent positive findings: constipation, weight gain, dry skin, cold intolerance, impaired memory, worsening depression, and fatigue Pertinent negative findings: enlarged thyroid, hoarseness, stiffness, muscle weakness and pain, tenderness, thinning hair, or bradycardia Type 2 DM: The pathophysiology of diabetes mellitus is frequently characterized by peripheral insulin resistance, impaired regulation of hepatic glucose production, and the decline of beta-cell function, thus leading to a beta-cell failure (McCance, Huether, Brashers, & Rote, 2019, p. 2169). To simply explain, type II DM is related to the levels of insulin in the body, and the body’s ability to utilize it. Usually, obesity is common in the abdominal region, generally occurs in those older than 40 years with a strong genetic predisposition, and often associated with hypertension and dyslipidemia (McCance, Huether, Brashers, & Rote, 2019, p. 2169). Symptoms associated with type II DM are polydipsia, polyuria, polyphagia, fatigue, neuropathy, weight loss or weight gain, irritability, skin infections, nausea, acanthosis nigricans, breath that smells fruity or sweet, and blurred vision (American Diabetes Association, 2020). Pertinent positive findings: fatigue, weight gain Pertinent negative findings: polydipsia, polyuria, polyphagia, neuropathy, blurred vision, nausea, acanthosis nigricans, fruity and sweet-smelling breath, and irritability. Chronic fatigue syndrome: is a disease marred by pain, fatigue, sleep defects, and other symptoms that are made worse by exertion and usually last longer than six months. It can also be characterized as flu-like symptoms that persist or recur with feelings of unrefreshing sleep, weakness, sore throat, muscle, and joint pain, problems with concentration, and new onset of headaches (Dains, Baumann, & Scheibel, 2020, p. 221). The patient’s physical exam may be normal with findings of tender cervical and axillary lymphadenopathy (Dains, Baumann, & Scheibel, 2020, p. 222). According to the Office of Women’s Health (2019), the symptoms of chronic fatigue syndrome can also be episodic. Pertinent positive findings: fatigue, weakness, unrefreshing sleep, weakness, worsening of symptoms on exertion Pertinent negative findings: headaches, muscle and joint pain, problems with concentration, sore throat Rank differential diagnosis: Hypothyroidism Type 2 DM Chronic fatigue syndrome Additional test or procedures “Testing of both the thyroid hormones and the TSH level allows determination of whether the thyroid dysfunction is related to a hypothalamic-pituitary issue or an end-organ issue” (McCance, Huether, Brashers, & Rote, 2019, p. 4684). To determine if hypothyroidism is the cause of the patient’s symptoms, obtaining labs for the thyroid-stimulating hormone (TSH, T3 and T4 levels may be necessary where in this diagnosis T3 & 4 is low with TSH elevated (Dains, Baumann, & Scheibel, 2020, p. 221)