Case Study For Patient With Excess Tiredness And Heavy Periods
Case Study For Patient With Excess Tiredness And Heavy Periods
Assignment:
Subjective: What details did the patient provide regarding her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan Case Study For Patient With Excess Tiredness And Heavy Periods
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SOAP NOTE Women’s Health
Patient information
Patient’s initials: S.W
Age: 40 years
Sex: female
Race: African American
Subjective Data
Chief complaint: tiredness and heavy periods.
History of presenting illness: Mrs S.W, 40 years old African American woman who presented with excess tiredness and heavy periods for 4months. It was of sudden onset. She also reports that she has noted weight gain over the past few months. She reports of mood changes alternating between elevated moods and extreme sadness. She states that these symptoms have reduced her productivity levels at home and at work and has tried several OTC drugs with no improvement Case Study For Patient With Excess Tiredness And Heavy Periods.
Current medication
Ibuprofen 400mg 8hourly
PO ranferon 10mls 12 hourly.
Allergies
No known food, drug or environmental allergies.
Past medical history
No history of chronic illness.
Social and substance history
She occasionally consumes alcohol occasionally during social gatherings. Denies use of tobacco products or illicit drug use.
Family history
She is the 2nd born in a family of three. All siblings are alive and well. Both parents are alive and well. Father is hypertensive while mother is diabetic Case Study For Patient With Excess Tiredness And Heavy Periods.
Surgical history
Has a history of tonsillectomy during childhood.
Mental history
No history of depression or anxiety.
Violence history
She has no concerns about her safety.
Reproductive history
She is para 3+0. All are term and born via spontaneous vertex delivery. Attained menarche at 15 years. The last normal menstrual period was on 28/6/2022. Her cycle is regular after 28 days. Lasts for 3-5 days. Has had heavy flow for the last 6 months. Denies dysmenorrhea or intermenstrual bleeding. Is currently on IUCD for contraception.
Review of systems
General: denies chills, fever and weight loss.
Neurologic: denies loss of memory, headache and convulsions.
HEENT: denies loss of hearing, ear pain, eye pain or discharge, runny nose, bleeding and sore throat.
Respiratory: denies chest pain, difficulty in breathing and cough.
Cardiovascular: denies palpitations, orthopnoea and paroxysmal nocturnal dyspnoea Case Study For Patient With Excess Tiredness And Heavy Periods.
GIT: denies constipation, diarrhoea and abdominal pain.
Genitourinary/ reproductive: denies dysuria, increased urinary frequency and urgency. Positive history of heavy bleeding. Denies dysmerrhoea or PV discharge.
Endocrine: denies excessive thirst, hunger and polyuria.
Psychiatry: denies self-harm/suicidal ideations. Positive history of mood changes and extreme tiredness.
Hematologic: denies easy bruisability. Positive history of anaemia.
Skin: no history of rash or itching.
Allergies
No history of eczema, asthma or rhinitis.
Objective Data
Physical examination
Vital signs: Bp- 105/78mmHg, PR- 54bpm, RBS- 6.8mmol/l, RR- 18bpm, BMI- 28kg/m2, Temp- 36.7, Spo2- 96% in room air
General Examination
Mrs S.W 40yr old, African- American woman is in a fair general condition, alert, oriented in time, place and person. She however seems to be in low moods.
Mental status assessment: Mrs.S.W is cooperative throughout. She maintains eye contact and is keen to listen. Has good communication skills and elicits composure when answering questions. She however seems disturbed because of her symptoms as they are impacting her personal and work life Case Study For Patient With Excess Tiredness And Heavy Periods.
Diagnostic Test
Thyroid Function Test: check the level of TSH, T3 and T4.
Complete Blood Count: check the haemoglobin level.
UECS: assess the kidney functioning.
Beck depression inventory: to screen for depression.
Assessment
Differential Diagnosis
Hypothyroidism:-a disease that results from reduced levels of thyroid hormones. It can either be primary or secondary. Common causes of Primary Hypothyroidism include; iodine Deficiency, Drugs, Thyroid Radiotherapy and others. Secondary Causes include; Sheehan’s Syndrome, Pituitary tumours, TRH deficiency, and tumours compressing the thalamus (Patil et al., 2022). Clinical manifestation includes; cold intolerance, facial puffiness, hair loss, constipation, menstrual cycle abnormalities, weight gain and others. Patients can also present with symptoms of depression, psychosis and anxiety. Case Study For Patient With Excess Tiredness And Heavy Periods
Goitre: refers to enlargement of the thyroid gland due to either physiologic or pathophysiologic agents. According to Can & Rehman, (2021) the clinical presentation; cough, dyspnoea, hoarseness and pressure sensation in anterior neck.
Depression: according to American Psychiatric Association, it is a mood disorder that results in persistent feeling of sadness and loss of interest (Chand & Arif, 2022). Patients often present with depressive disorders of emptiness, sadness or irritable mood, accompanied by cognitive and somatic changes that significantly affect the individual’s capacity to function.
Plan
PO levothyroxine 50mcg OD
Patient education
Advise patient to take the medication on an empty stomach at least 30 minutes before eating and at least the same time every day.
Educate the patient on need for lifelong levothyroxine therapy and the need for TSH testing at least annually.
Educate on weight management involving incorporating healthy dietary plans and low impact exercises. Case Study For Patient With Excess Tiredness And Heavy Periods
Follow up after one week to monitor progress.
Reflection
This case study gave me an opportunity to provide holistic care in patient management. It I learnt that patient education is essential and affects the overall outcome. There is nothing I would have done differently in regards to diagnosing, treatment and educating the patient.
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References
Can, A. S., & Rehman, A. (2021, August 30). Goiter. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562161/
Chand, S. P., & Arif, H. (2022, May 8). Depression. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430847/
Patil, N., Rehman, A., & Ishwarlal Jialal. (2022, February 6). Hypothyroidism. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519536/ Case Study For Patient With Excess Tiredness And Heavy Periods