Chief Complaint (CC): Patient feels tired, and her hair keeps falling out
History of Present Illness (HPI): A 32-year-old female, Chantal, checks in the facility complaining that she feels bored, and her hair falls out. In the past year, she gained 30 pounds but recorded her reduced appetite. She indicates sleep difficulties as she often feels cold on ROS. The patient is vibrant as she keeps up with her hobbies, though not aware, she is depressed.
Medications:
Currently, the patient takes the following medications
- Dexedrine 5 mg take after 8 hours for three days. The drug is either a prescription or an over-the-counter (RX/OTC).
- Lunesta oral 1mg, which helps her in improving her sleeping habits. She has taken the medication for almost a month. The drug may be RX/OTC.
- 300 mg Ibuprofen tablets for the last 48 hours. She takes medicine to relieve her pain. The medication is over-the-counter.
- Lorcaserin hydrochloride tablets 10 mg BID orally. She has been taking the drug for one month, intending to lower her weight. The medicine is OTC.
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Allergies:
The patient is allergic to eggs, spices, and Sulfa drugs – rash.
Past Medical History (PMH):
- Tetanus immunization
- Gastroesophageal reflux (GERD)
- Influenza immunization
Sexual/Reproductive History: If applicable, including obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: CH has been married for 15 years. Her husband is 38 years old. This means CH is younger than her spouse. The two have four children, two daughters, and two sons. The most former is 12 years, the second one is 10, the third is eight while the youngest is five years old. The patient reports they live together in Suffolk county, New York. She works as a data analyst at NBC studios. The patient notes that she has not used tobacco or any illicit drug use. CH occasionally drinks wine or whiskey.
Immunization History: the patient has been immunized against flu and tetanus
Significant Family History:
Father- deceased due to natural death.
Mother 65- type 2 diabetes, hypertension.
Brother 40- no health problems
Brother 29- obesity and heart disease
Brother 28- hypertension and type 2 diabetes
Lifestyle: CH is financially stable as the family enjoys their wealth without having or developing any predicament. CH enjoys fun activities like fishing, cycling, volunteering work, drama, and poetry. The patient loves social work and looks after the needs of her community.
Review of Systems
General: CH contends that her hair falls out, and she is often tired. The patient reports on the difficulties when it comes to sleeping as she feels cold throughout. Last year she added 30 pounds. The patient acknowledges decreased appetite. CH does not give in to the fact that she is depressed.
HEENT: The patient denies feeling headaches of experiencing light-headedness. EYES: CH wears photochromatic lenses. The patient does experience blurred vision nor glaucoma. EARS: The patient acknowledges not having hearing problems nor ear problems. NOSE: the patient does not experience congestion and denies sneezing. THROAT: the patient has red tonsils. Besides, she mentions having trouble swallowing and slight irritations.
Neck: The patient does not feel any pain on the neck.
Breasts: CH reports no changes in her breast. No visible lesions nor lumps
Respiratory:
Cardiovascular/Peripheral Vascular: Patients denies feeling chest pain
Gastrointestinal: CH accepts experiencing decreased appetite. At the same time, CH says no abdominal pain, no diarrhea, no vomiting, no nausea, no bloating, and no heartburns.
Genitourinary: CH reports regular urinary frequency. The patient admits no nursing sensation when urinating and no dysuria.
Psychiatric: No mood changes and no visible sign of depression
Neurological: The patient reports feeling cold on the hands and feet. No change in sensation
Skin: No, rashes, lumps, sores, itching, dryness, switches, etc.
Hematologic: No blood problems
Endocrine: CH denies thyroid problems as she affirms no to polyuria, no to polyphagia, and no polydipsia. The patient accepts a recent weight increase.
Allergic/Immunologic: the patient has mild allergies and healthy immune system
OBJECTIVE DATA
Physical Exam:
Vital signs: Blood pressure (BP) is 115/80, oral temperature (T) is 97.5 degrees. The respiratory rate (RR) is 18, heart rate (HR) is 19, height is 5′ 6″, weight is 190 lbs, and BMI is 28.1.
General: CH is an African American female, aged 32 looking well-nourished. The patient is overweight. CH is oriented and alert. Her speech and language are clear and understandable. The patient displays and denies no flight of ideas, obsessions, compulsion, delusion, illusion, and hallucination
HEENT: HEAD: No notable pressure upon checking frontal sinuses and maxillary sinuses. No observable sinus tenderness. When palpating, no detectable lymph node enlargement or tenderness was noticed. EYES: the presence of white sclera though no signs of jaundice. Conjunctivas are pink and moist. Pupils 4mm constricting EARS: Bilateral canals are patent and intact with non-tender. The hearing is appropriate for her age. No vertigo or tinnitus noted. No edema, no lesion, and no exudate present. NOSE: Turbinates are intact, but pink and presence of thin clear mucus drainage from the nose. Nares are patent. THROAT: In the middle position, the uvula is visualized. The gag reflex is remarkably intact. The tongue is symmetric, with no abnormal findings.
NECK: The patient’s trachea is midline, the thyroid is non-tender, and there is a thyroid nodule.
RESPIRATORY: Respiration rate is 17 breaths in a minute with vesicular breathing sound. Thorax is non-tender with no masses, but there are nodules palpated.
CARDIOVASCULAR: The extremities are dry but warm; they are well perfused with about 2+ palpable pulses. The latter are bilaterally in the radial and the dorsal pedis pulses. The carotids are auscultated bilaterally and revealed no bruits, and the nail beds are pink with < 2 for the capillary refill. The extremities showed no cyanosis, no clubbing, and no edema.
GASTROINTESTINAL: The abdomen is round and slightly big associated with age and fat around the stomach, but the belly is non-distended, with no rigidity or guarding, and no masses present. The patient displayed mild tenderness in the epigastric region, but no reflex tenderness, and negative for Murphy’s sign.
GENITOURINARY: The patient experiences normal urethral meatus with no discharge or infection.
MUSCULOSKELETAL: the range of motion of patient is within normal limits
ASSESSMENT
Labs/ Diagnostic Tests
To gather more information from CH’s condition, the following labs or diagnostic tests are important;
- a) Thyroid-stimulating hormone (TSH) test to confirming the amount or level of TSH in the blood. TSH is a hormone that is found in the pituitary gland (Carty, Doogan, Welsh, Dominiczak & Delles, 2017). The test is ideal in confirming the functionality of the thyroid gland.
- b) T4 tests, for differentiating whether a person has hyperthyroidism or hypothyroidism. A low blood level of T4 prompts hypothyroidism while a high blood level of T4 prompts hyperthyroidism (Trumpff et al., 2015).
- c) T3 tests, which is used to confirm the diagnosis of hyperthyroidism.
- d) Thyroid antibody tests for measuring thyroid antibodies in the blood, thus helping in diagnosing autoimmune thyroid disorders such as Grave’s disease (Mao et al., 2015).