Free Essay Example: Fatigue, Hair falling out.

HPI: A 32 year old Caucasian female experiencing low energy levels for one week, experienced throughout the day. She has also noted the increased amount of hair loss, can pull strands of hair by running fingers through it.

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Over the last year, the patient has gained weight, 30 pounds, but reports to have decreased appetite over the same period.

The patient also has cold intolerance, feeling cold all the time even on relatively warm days. She also experiences difficulty in sleeping at night.

She is currently on no medication and has no known allergies.

PMHx: Surgery on the right leg to fix a fractured tibia as a result of a car accident. Done in 2011.

She has no history of chronic illness nor is she on any medication on the same.

The last tetanus shot was administered in November 2011.

SOC Hx: Chantal works as a sales assistant at a real estate firm, the work involves hours of traveling, standing, and interacting with potential clients. She is not able to complete a full workday due to fatigue and often has to take breaks.

She is married and has no children out of choice.

Occasionally drinks alcohol, once a week, and does not smoke.

She enjoys swimming and cooking, she is still able to these activities on occasions. She has however had to cut on her morning runs due to fatigue.

Apart from the tiredness, she has maintained good working and social relationships and shows no sign of depression.

Fam Hx: Both her parents are alive. Her mother is in good health her father was diagnosed with hypertension at the age of 60 and is on medication to manage the same.

Her maternal aunt was diagnosed with thyroid cancer at the age of 46 had treatment of the same including surgery and is now on remission for two years post-treatment.

Her maternal uncle was also diagnosed with goiter at the age of 40 and this was treated, he has had no further issues concerning this.

Objective

ROS:

GENERAL: weight gain, 30 pounds over one year. Experiences fatigue and chills. No fever, joint pain, and muscle cramping.

HEENT: Face is slightly puffy, has thinning of hair, the eyes are clear, no loss of vision and eye dryness.

No discharge from the ears and does not have any pain in the ears. Clear nose, no plugged up phlegm, no runny nose.

The patient has not had any soreness of throat or hoarseness of voice.

SKIN: Skin is dry, with no itching or rash visible.

CARDIOVASCULAR: Slowed heart rate, no chest pain, no chest pressure or edema.

RESPIRATORY: Experiences shortness of breath. She has no cough or sputum production.

GASTROINTESTINAL: No abdominal pain or distension. No nausea, vomiting or diarrhea, no blood in the stool.

GENITOURINARY: No burning sensation during urination, no blood in the urine. The patient is not pregnant and had her last menstrual period on 11/ 22/2019. She has had regular menses for the last six months.

NEUROLOGICAL: No headache, dizziness, paralysis or numbness and tingling at the extremities.

MUSCULOSKELETAL: She has muscle weakness and aches. No stiffness, back pain or joint pain.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATIC: No enlarged lymph nodes.

PSYCHIATRIC: No history or signs of depression or anxiety.

ENDOCRINOLOGIC: Has cold intolerance.

ALLERGIES: No history of any allergies.

Assessment

PHYSICAL EXAM:

The patient appears tired and has rapid breathing. She is covered up indicating that she is feeling cold.

Dry brittle and coarse hair, the hair has thinned out. There is periorbital puffiness on the eyes, the eyes are clear, no dryness and there is no paleness indicating anemia. The ears are clear no discharge present. The nose is also clear has no discharge.

The throat is clear, with no redness or visibly swollen tonsils. There is no dryness of the mouth or discoloration.

No palpable lymph nodes on the head and neck region. There is however an enlarged thyroid gland that is palpable.

The skin on the hands is dry and the nails are brittle, capillary circulation to the fingertips is sufficient, there is no discoloration on the palms. The pulse rate is at 54 beats per minute.

There is delayed relaxation upon conducting a deep reflex test on the biceps.

There is an increased respiratory rate of 30 breaths per minute. No bruising or discoloration on the chest cavity and there are no chest murmurs.

No abdominal distention, tenderness or discoloration.

No edema or swelling and stiffness on the legs.

DIAGNOSTIC RESULTS: TSH assay, T4, and T3 Analysis, Calcitonin level assay (Maria, 2019).

DIFFERENTIAL DIAGNOSIS:

Hypothyroidism

Hashimoto's disease.

Goiter (Canaris, 2007).

Plan

Daily intake of thyroid hormone levothyroxine (Pinsky, 2017).

References

Canaris GJ, Steiner JF Ridgeway C (2007). Do Traditional Symptoms of Hypothyroidism Correlate With A Biochemical Disease? J Gen Intern Med; 12:544-550. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/9294788

Maria M, (2019). Hashimoto Thyroiditis - Hormonal and Metabolic Disorders " Merck Manuals Consumer Version. Retrieved 26 December 2019 from: https://www.maria-online.us/health/article.php?lg=en&q=Hashimoto%27s_thyroiditis

Pinsky LE, (2017). Common Thyroid Disorders. In: Fihn SD, DeWitt DE, eds. Outpatient medicine. 2nd ed. Philadelphia: WB Saunders:493-502.