diagnostic

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Final Assessment

United States University

MSN 572 Health and Physical Assessment Across the Life Span

Adrean Knight, RN BSN FNP-Student

Katherine Martin-Goodhart , RN MSN FNP-Student

June 26, 2021

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SUBJECTIVE:

ID: 42 year old Caucasian female JW. She presented to the clinic for a complaint of constipation and lethargy. She drove herself unaccompanied and she is a reliable historian.

CC: She is here for “I have been constipated for two months and have tried doing more fiber and water and it didn't help, I am also very lethargic “.

HISTORY OF PRESENT ILLNESS (HPI):

The patient presents to the clinic for a complaint of constipation She has a complaint of being constipated for two months and is chronically tired. She has increased her fiber and water and still remains constipated. She also complains of being chronically tired and falling asleep frequently during the day. Patient denies pain from constipation verbalizes is, “uncomfortable”. She has noted an eight pound weight gain in the last two months. She has not been able to exercise as she did since these symptoms occurred. She complains of feeling cold frequently, her hair is thinning and falling out and her skin feels exceptionally dry despite her increasing her water intake. She has no other complaints at this time.

PAST MEDICAL HISTORY

Medical Problem List: Denies any past, current medical problems. .

Surgeries/Hospitalizations: Primary cesarean section elective 2001 uncomplicated, Repeat cesarean section 2003 uncomplicated. Denies any other surgery or hospitalizations.

Immunizations: Stated up to date on all immunizations, Covid vaccinated three doses, Flu vaccine annually.

Allergies: Denies allergies to medication, food, dust, seasonal allergies or latex.

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Medications: Daily multivitamin as prescribed on the bottle. Kombucha drink for probiotic use every day. Denies other vitamins, supplements or herbs.

Family History: Maternal grandfather deceased unknown age of blood cancer. Maternal grandmother deceased of natural causes, unknown year. Mother age 73 breast cancer stage four, treated and in remission for five years- 2016. Father age 73 no significant medical history. Son age 21 years no significant medical problems. Daughter 19 years old and has no significant medical problems. Unknown medical history of any additional relatives.

Chemicals; Denies tobacco, vaping, e cigarettes, Alcohol occasionally/social 2 times per week ”hard seltzer”, denies illicit drug usage.

Diet/Exercise: Regular diet, Caffeine 2 cups coffee per day, Exercise at gym three times per week.

Psychiatric: Denies any psychiatric illness, suicide ideation.

Sexual/Reproductive: Sexually active, denies STI, sexual difficulties, verbalizes has birth control implant, verbalizes name of implant “ESURE”. Regular Menstrual cycles with no heavy bleeding or pain.

Social History:

Occupation/Marital/Relationship Status/ Current Living Situation: Married for twenty two years, Full time real estate agent. Lives with husband and adult 21 y.o son in a one story home, feels safe in her home.

Spiritual/Social: Chrisitan, attends church weekly, large family in the area for support.

Safety: wears seat belt 100% of time, denies texting and driving, guns in home unlocked and loaded, fire extinguisher in home-recites how to use, smoke detectors in home. No pool on property.

Sleep/Anxiety: sleeps 7 hours uninterrupted, denies anxiety, chronic fatigue and lethargy, naps every day.

Review of Systems:

Constitutional - has chills and no fever, denies headaches, Eight pound weight gain in two months.

Eyes: Wears glasses for distance, denies reading glasses.

Ears: Denies hearing loss, tinnitus, vertigo, ear issues of any kind.

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Cardiovascular: Denies angina, arrhythmias,, denies additional heart issues of any kind.

Respiratory: Denies difficulty breathing, wheezing, coughing up blood or sputum.

Gastrointestinal: Denies abdominal pain, rectal bleeding. Constipation for two months.

Musculoskeletal: Denies muscle, joint and skeletal issues of any kind.

Integumentary/Breast: Denies any skin changes, moles, rashes, or issues of any kind. Denies any breast disorders and is scheduled for her regular mammogram in June.

Neurologic: Denies any neurological issues of any kind.

Psychiatric: Denies any psychiatric issues of any kind.

Hematologic/Lymphatic: Denies and hematologic/lymphatic issues of any kind.

Endocrine: Denies any endocrine issues, denies diabetes.

Allergic/Immunologic: Denies any allergies to medication, latex, animals, seasonal pollen or dust, and/or immunologic issues of any kind.

OBJECTIVE

BP 100/78 HR 58 RR 18 T97.8 O2 SAT 98%

135 pounds, 5 feet 5 inches

5/122022 Lipid panel normal, Cmp normal, CBC normal, TSH pending, A1C 5.7

Physical

General Survey

Head: round, symmetrical, hair coarse and thinning.

Eyes; no abnormal findings

Ears: no abnormal findings

Nose; no abnormal findings

Throat: no abnormal findings

Neck: no abnormal findings

CV: no abnormal findings

Pulm: no abnormal findings

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Abdominal/GI: hypoactive bowel sounds lower left quadrant. No pain/ rigidity of abdomen.

GU: no abnormal findings

M/S: no abnormal findings

Lymph: no abnormal findings

Skin: dry to touch, +2 non pitting edema lower ankles bilaterally.

Neuro: no abnormal findings

Psych: no abnormal findings

Differential Diagnosis:

1. Hypothyroidism is related to changes in skin and hair, chronic lethargy, constipation, weight gain over two months.

2. Chronic Fatigue Syndrome related to inability to complete ADL’s without need for rest and chronic exhaustion.

3. Peri menopause related to maternal age and hormonal shift.

Diagnosis:

Hypothyroidism

Hair loss and brittle texture, excessive dry skin, excessive and chronic fatigue.

Plan

Obtain TSH

Follow up visit in one week with lab results.

Anticipate Levothyroxine as indicated by lab results.

Anticipate Lab work to be ordered for 6 weeks post treatment of Levothyroxine.

Lab work for FSH hormone levels, treated as indicated.

Miralax OTC as directed on bottle and as needed for constipation.

Colace 250 mg BID until regular soft bowel movements daily.

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Education

Provide signs and symptoms of thyroid toxicity.

Educate the patient to take medication as prescribed every day prior to breakfast.

Discuss and review timely lab draws for monitoring thyroid levels.

Provide education on perimenopause and treatments available for symptoms.

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References

American Clinical Practice Guidelines, American Association of Clinical Endocrinologists and The American Thyroid Association

Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. (2021, January 1). Bates' Guide to Physical Examination and history taking, 13e. Bates' Guide to Physical Examination and History Taking, 13e | Medical Education | Health Library. Retrieved June 2, 2022, from https://meded.lwwhealthlibrary.com/book.aspx?bookid=2964

Maldonado, D. C., & Zúñiga, C. (2019). Soap for family medicine. Wolters Kluwer.

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