Discussion: Clinical Case Study Part One
Discussion: Clinical Case Study Part One
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Summary of History and Physical Findings
In this case, we have a 56-year-old Caucasian female patient presents with symptoms of generalized fatigue that began 2-3 months ago. The patient reports that she has low energy levels and hypersomnia. ROS reveals weight gain, generalized weakness, worsening depressive symptoms, cold intolerance, and calf muscles cramping. She denies having suicidal or homicidal ideations. She is currently, on Multivitamin, B-Complex, Prozac, Bisoprolol-HCTZ, Calcium and Vitamin D3 supplements. She has a history of depression and HTN and is allergic to iodine dyes. Positive family history of HTN, Hyperlipidemia, and T2DM. She is married, has two grown kids, and the youngest child has a history of bipolar depression, ADHD, and anxiety disorder. She occasionally takes wine but denies cigarette smoking or drug use. On physical exam she is overweight, BP is 146/95, the thyroid is small and firm without palpable masses, the skin is dry, and has coarse and thick hair. She has a pleasant and appropriate mood pleasant, and other systems were normal.
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Differential Diagnosis
[elementor-template id="165244"]Hypothyroidism: Hypothyroidism is an endocrine disorder that results from a deficiency of thyroid hormone. The condition is caused by hypothalamic or pituitary diseases and thyroid gland diseases resulting in a decreased production of thyroid hormone (Taylor et al., 2018). Symptoms include: fatigue, low energy levels, weight gain, decreased appetite, cold intolerance, dry skin, and sleepiness, weakness in the extremities, muscle pain, and depression (Taylor et al., 2018). Physical exam findings include weight gain, dry skin, slowed movements, coarse and straw-like hair, simple or nodular goiter, bradycardia, and dull facial expressions (Patil & Jialal, 2019). Allergy to iodine dyes put the patient at a high risk of having a deficiency of thyroid hormones since iodine is required for normal thyroid function. Hypothyroidism is the most likely diagnosis based on the patient’s history of fatigue with low energy levels, hypersomnia, general weakness, weight gain, cold intolerance, calf muscles cramping, and depressive symptoms. The patient also has positive findings of dry skin, coarse hair, overweight, and a firm thyroid gland.
Major Depressive Disorder (MDD): MDD is thought to be caused by a disturbance of neurotransmitters in the central nervous system resulting in a decrease in serotonin, and norepinephrine levels (Otte et al., 2015). MDD is diagnosed when at least five of the following are present: depressed mood, loss of interest, weight and appetite changes, sleep disturbances, fatigue, psychomotor retardation, and feelings of worthlessness, indecisiveness and suicidal ideations (Otte et al., 2015). MDD is a possible diagnosis based on positive history, of fatigue, loss of energy, hypersomnia, worsening depressed mood, and weight gain in the past two months. Negative findings include appetite changes, psychomotor retardation, and indecisiveness. Patient’s findings of cold intolerance, calf muscles pain, and a firm thyroid gland make MDD an unlikely diagnosis.
Anemia: Anemia is characterized by a reduction of hemoglobin in red blood cells (RBCs). The decrease in RBCs may be caused by blood loss, decreased production, or increased destruction (Powers & Buchanan, 2014). RBCs are involved in the transportation of oxygen, and deficiency of the cells results in an impaired ability of the body to exchange oxygen and carbon dioxide. Patients present with symptoms of easy fatigue, low energy levels, leg cramps, cold intolerance, poor concentration, and recurrent infections (Powers & Buchanan, 2014). Anemia is a differential diagnosis based on symptoms of fatigue, loss of energy, cramping calf muscles, and cold intolerance. However, the presence of depressive symptoms makes it an unlikely primary diagnosis.
Additional Diagnostic Procedures
I will conduct a Thyroid-stimulating hormone test to evaluate the TSH, and T4 levels help in confirming the presence of hypothyroidism. Elevated levels of TSH with decreased T4 point to hypothyroidism. The TSH level should first be monitored, and if elevated, FT4 levels should be measured, either directly by T4 RIA or approximated by obtaining a total T4 and a T3 resin uptake (Peterson, 2016). A complete blood count to evaluate the presence of anemia, which could be the cause of fatigue and general body weakness (Powers & Buchanan, 2014). I will also screen for depression to evaluate the severity of the depressive symptoms.
References
Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., Mohr, D.C., & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2, 16065.
Patil, N., & Jialal, I. (2019). Hypothyroidism. In StatPearls [Internet]. StatPearls Publishing.
Peterson, M. E. (2016). Diagnosis and management of iatrogenic hypothyroidism. August’s Consultations in Feline Internal Medicine, 7, 260-269.
Powers, J. M., & Buchanan, G. R. (2014). Diagnosis and management of iron deficiency anemia. Hematology/Oncology Clinics, 28(4), 729-745.
Taylor, P. N., Albrecht, D., Scholz, A., Gutierrez-Buey, G., Lazarus, J. H., Dayan, C. M., & Okosieme, O. E. (2018). Global epidemiology of hyperthyroidism and hypothyroidism. Nature Reviews Endocrinology, 14(5), 301.
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