Running head: Week six case study 1
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Differential Diagnosis and Primacy Care Practicum Chamberlain College of Nursing Course Number: NR 511
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June 11, 2019
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1. Summarize the history and physical (H&P) findings: date of visit: November 7, 2017 56 y/o Caucasian female presented with history of hypertension and depression. She reports to clinic with CC of fatigue for the past 2-3 months. She describes herself as not feeling well rested even after 8 hours a sleep per night. She is constantly tired, lacks energy to perform daily activities. The fatigue is worsens with exertion and she has not identified any alleviating factors or interventions to improve her energy levels.
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HPI: constipation, generalized weakness, and muscle cramping intermittently to calves, cold intolerance, as well as worsening depression due to feeling unproductive. She denies sleep disorders and any complaints of sleep apnea. Denies suicidal or homicidal ideation. Denies polyuria and polydipsia.
ROS/PE On physical exam, she is alert and oriented, no apparent distress. Skin dry skin, hair course and thick, nails without abnormality. HEENT unremarkable. Thyroid was noted to be midline, small and firm with no palpable mases. Heart and lung sounds normal, Abdomen unremarkable. Strength of extremities 5/5 throughout and DTRs there were 2+ at bilateral biceps, but 1+ at both knees and ankles. BP 146/95, Height 5”7” and Weight 180 pounds. She has a family history of Type 2 DM, HTN, HLD and heart disease. She has a 24 year old child with bipolar depression, ADHD, anxiety. SxH Tonsillectomy. PSH married, with 2 kids (adult). She is an office manager in a physician office full time. Nnonsmoker, drinks infrequently Allergies include iodine dyes. Current medications: Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Multivitamin, B-Complex, Calcium 500mg + Vit D3 400IU. 2. Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement of pathophysiology for each
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Diagnosis #1: Hypothyroidism
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Hypothyroidism is a metabolic disorder which results from decreased free thyroid hormone or resistant of hormone action. It is condition in which the thyroid gland is not able to produce enough thyroid hormone. Hyperthyroidism is more prevalent in women then in men. There are two fairly common causes of hypothyroidism, the first. Autoimmune, (Hashimoto's thyroiditis), a form of thyroid inflammation caused by the patient's own immune system. The second cause is the broad category of "medical treatments." The treatment of many thyroid conditions warrants surgical removal of a portion or all of the thyroid gland. Signs and symptoms may include fatigue, weakness, cold intolerance, muscle cramps, weight gain and depression. (Jonklaas J, Bianco AC, Bauer AJ, et al, 2014).
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Diagnosis #2 Anemia Anemia is a disorder that results in depletion of iron stores causing a decrease in reticulocyte and hemoglobin, it can be defined as a reduced absolute number of circulating red blood. Anemia occurs due to lack of the production of red blood cells which carry oxygen to tissues, and lack of this vital oxygen delivery system. Anemia can be caused by a multitude of problem with a small list of being iron deficiency, blood loss anemia, and simply vitamin deficiency anemia. Causes may be related to blood loss, poor iron intake, pregnancy, and breastfeeding. Predominantly found in females, pregnant females, and those of Mexican-American and African descent. Symptoms may include weakness, fatigue, headaches, cool extremities and tachycardia. (Stauder, Valent, & Theurl, 2018). Diagnosis #3: Major Depressive Disorder
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This is chronic condition that stems from a deficiency of neurotransmitters, such as serotonin, norepinephrine, and acetylcholine, in the brain (Dunphy, Winland-Brown, Porter, & Thomas, 2014). When these neurotransmitters are in short supply, patients can experience a wide variety of negative emotional experiences, ranging from sadness to decreased interest in activities they typically enjoy. Major Depressive disorder my third differential, the patient has a past medical history of depression. The symptoms presented could be related to depression. The complaints of lack of energy and weight gain could be directly related to depression. Symptoms include fatigue, weight gain, depressed mood, diminished interest or pleasure in usual activities, or an inability to concentrate (Maurer et al., 2018). 3. Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
Diagnosis #1: Hypothyroidism Pertinent positive findings: weakness, fatigue, modest weight gain, cold intolerance, constipation, dry skin, delayed reaction phase on DTR’s, muscle cramps and depression.
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Pertinent negative: no autoimmune disorder, no known family history or use of medications that affect thyroid function. No hair loss or brittle nails. No signs of slowed speech or bradycardia.
Diagnosis #2 Anemia
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Pertinent positive findings: weakness (“no energy”), fatigue, cool extremities. Pertinent negative findings: dyspnea upon exertion, pica, chest pain, pallor, tachypnea, and tachycardia, jaundice and pallor or postural hypotension. No history of iron deficiency, blood loss anemia, or vitamin deficiency anemia. Diagnosis #3: Major depressive disorder Pertinent positive findings: history of depression and is taking Prozac, there is a possibility that her symptoms are simply not well-controlled at this. She reports missing work due to extreme fatigue and not able to complete daily actives.
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Pertinent negative findings: Denies and suicidal or homicidal ideations. No complaints of insomnia or hypersomnia, diminished interest or pleasure in usual activities, feelings of worthlessness or guilt, psychomotor agitation, or an inability to concentrate. 4. Rank the differential in order of most likely to least likely. a. Hypothyroidism b. Anemia c. Depression
5. 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.
Based on subjective and objective pertinent findings, I would check thyroid function and order serum TSH and free T4 (FT4) level. A TSH and T4 are essential at this time to determine if she is having issues with her thyroid (Jonklaas, Bianco, Bauer, Burman, et. al, 2014). Other testing I would include a lipid panel since hypothyroidism can have many secondary disease processes with hyperlipidemia due to significant family history of hyperlipidemia
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I would also perform a PHQ-9, which is a patient health questionnaire that would determine her level of depression (Manea, Gilbody & McMillan, 2015).
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I would check CBC with differential to rule out elevation of WBC/infectious process as well as evidence for increased red blood cell, or iron deficiency to rule out anemia. I would also check for deficient in folate, vitamin D due to fatigue, and BMP to determine if there is any electrolyte abnormality or dysfunction of her renal system.
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References Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The advanced practice nursing (4th ed.). Philadelphia, PA: F. A. Davis Company Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 2014; 24:1670.
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Manea, L., Gilbody, S., & McMillan, D. (2015). A diagnostic meta-analysis of patient health questionnaire-9 (PHQ-) algorithm scoring method as a screen for depression. General Hospital Psychiatry, 37(1). 67-75. Maurer, D., Raymond, T., Davis, B. (2018). Depression: Screening and diagnosis. American Family Physician, 98(8), 508-511.
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Stauder, R., Valent, P., & Theurl, I. (2018). Anemia at older age: etiologies, clinical implications, and management. Blood 2018, 131. 505-514. doi: Caution-https://doi.org/10.1182/blood-201707-746446 < Caution-https://doi.org/10.1182/blood-2017-07-746446
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