Analysis of the Differential based on the History and Findings.

Posted: January 19th, 2023

Analysis of the Differential based on the History and Findings.

 

Case Study Part One

Clients present chief complaints that might characterize the various condition. Therefore, a clinician tends to conduct a differential diagnosis to rule out the client’s condition. This paper covers three differential diagnoses conducted on 56-years old female to rule out her condition. It also summarizes the provided history and the findings of the physical exam. Finally, it captures additional tests that should be conducted. Analysis of the Differential based on the History and Findings.

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Summary of the History and Physical Findings

Upon visiting the clinic on November 7, 2017, the client who is Caucasian female aged 56 years complains of fatigue. More questions revealed that the client had been struggling with the condition for 2-3 months. The fatigue was general and constant. Since its onset, the fatigue had been worsening progressively making her feel tired most of the time. She did not relax despite sleeping for 8hrs per night. Thus, she was left with no energy to perform her duties. Nothing had been identified to relieve the pain. Additionally, no treatment had been prescribed to manage her condition. Depressive symptoms were reported to be worsening, thus triggering homicidal or suicidal thoughts.Nonetheless, she denies any pain. In addition to questioning, physical examination revealed more details regarding her condition. Her temperature was 98.2 while BP was 146/95. Her head was normocephalic and atraumatic. Besides, her skin was overall dry. Finally, she had an appropriate and pleasant mood.Analysis of the Differential based on the History and Findings.

Differential Diagnosis

Hypothyroidism (Hashimoto’s thyroiditis)

Hypothyroidism is a disorders that occurs due to the failure of thyroid gland to secret adequate amount of a particular crucial hormones (Dunphy et al., 2019). The prevalence of this condition increases due to genetics and environmental factors. Additionally, the prevalence of Hypothyroidism is relatively high among older women (Dunphy et al., 2019). Thyroid antigens are attacked by the body resulting in a continuous cycle of immune response making thyroid follicles to deteriorate with time.  This process, in turn, declines the amount of thyroid hormones, which lowers the overall basal metabolic rate and other activities in the body (Dunphy et al., 2019).Analysis of the Differential based on the History and Findings.

Obesity

This condition is associated with an imbalance between caloric intake and energy expenditure(Gadde et al., 2018).This condition is characterized by weight gain, fatigue in the whole body, decreased energy, and depression (Dunphy et al., 2019).Analysis of the Differential based on the History and Findings.

Stage 2 Hypertension

This condition is associated with a chronic rise in the level of blood pressure. Individuals diagnosed with this condition have a systolic pressure and a diastolic pressure of 140 mm Hg and 90or high respectively.

Analysis of the Differential based on the History and Findings

Hypothyroidism (Hashimoto’s thyroiditis)

Positive subjective and objective findings were reported.

Positive subjective findings: Generalized fatigue, 5 lbs weight gain, mild depression, constipation and generalized weakness.

Positive objective findings: Dry skin and coarse and thick hair

Negative findings:  No hypersomnia, memory deficits, and nausea.

Obesity

Both positive and negative symptoms were present.

Positive subjective findings: Generalized and constant fatigue, 5 lbs weight gain in the past 6 months, mild depression, decreased energy, and inability to perform normal duties.

Positive objective findings:Relatively higher BMI, 28.2.

Negative findings: Social isolation

Stage 2 Hypertension

Positive subjective findings: Generalized and constant fatigue,

Positive objective findings: High BP, 146/95.

Negative findings: Severe headache and vision problem

Ranking of the Differential

Hypothyroidism

Obesity

Stage 2 Hypertension

Additional Tests

More tests were required to rule out the client’s condition. A blood test in particular would be conducted to check the level of thyroid hormones and cholesterol in the blood. According to Lalem et al (2015), the level of cholesterol and triglycerides is relatively high among individuals struggling with obesity.

Three differential diagnosis should be conducted on this client: Hypothyroidism, obesity, and stage 2 hypertension. It was recommendable to conduct a blood test to rule client’s condition.

1. Briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information.Analysis of the Differential based on the History and Findings.

The patient is a 56 years old Caucasian female with complaints of generalized fatigue which has been going on for the past 2 to 3 months.  The patient states that it has progressively worsened since onset, feels tired all the time despite getting 8 hours of sleep per night.  She states that she has no energy to do normal activities that she was able to do in the past.  Any exertion makes it worse, and she missed 1 day of work two weeks ago because she wasn’t able to get out of bed.Analysis of the Differential based on the History and Findings.

The patient denies any fever, chills, or recent illness.  ROS is positive for weight gain of 5lbs since six months ago, constipation, cold intolerance, and worsening of depressive symptoms due to being “unproductive” lately and feeling tired all the time.  She denies any suicidal or homicidal thoughts.  She has generalized weakness and intermittent muscles cramping in calves.

The patient is alert, awake and oriented.  She is pleasant and cooperative.  Her BP is 146/95 and other vital signs are stable. Her BMI is 28.2.  Her thyroid is midline, small and firm without palpable masses.  Her skin is overall dry, hair coarse and thick, nails without ridging, pitting or discoloration.  The rest of her physical exam is normal.Analysis of the Differential based on the History and Findings.

Medical history of hypertension, depression, and menopause (5 years ago).

Surgical history of tonsillectomy as child.

Allergic to Iodine dyes.

Medications list:  Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, 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.Analysis of the Differential based on the History and Findings.

Hypothyroidism (Hashimoto’s thyroiditis)

Hashimoto’s thyroiditis is an autoimmune condition and a very common cause of hypothyroidism (Dunphy et al., 2019).  This condition tends to form in individuals who have genetic susceptibility along with environmental aspects.   The body attacks its own thyroid antigens which causes continuous cycle of immune response that leads to deterioration of thyroid follicles.  This results in low levels of thyroid hormones which decreases overall basal metabolic rate, slows bodily functions, and metabolic processes (Dunphy et al., 2019).Analysis of the Differential based on the History and Findings.

Major Depressive Disorder (MDD)

An individual experiencing negative changes in mood, thinking, and behavior can be experiencing MDD (Dunphy et al., 2019).  The authors discuss a relationship between depression and increased secretion of cortisol.  Genetic factors and stressful life events also play a huge role in development of MDD.  The screening of MDD can be done by asking patients if they have felt hopeless over the past weeks and if they had little or no interest in doing things that they used to enjoy doing (Dunphy et al., 2019). Analysis of the Differential based on the History and Findings.

Cushing’s Syndrome

Cushing’s syndrome is caused by hypersecretion of adrenocorticotropic hormone (ACTH) by the adrenal cortex either due to cortical hypertrophy or an abnormal growth of the adrenal gland (Dunphy et al., 2019).   It can also be caused by an intake of large doses of exogenous glucocorticoid hormones (Dunphy et al., 2019). Analysis of the Differential based on the History and Findings.

3. Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.

Hypothyroidism (Hashimoto’s thyroiditis)

Pertinent Positives:  Generalized fatigue, 5 lbs weight gain, cold intolerance, mild depression, intermittent muscle cramping in calves, generalized weakness, and constipation {Subjective findings}.  Dry skin, coarse and thick hair {Objective findings}.

Pertinent Negatives:  No complaints of hypersomnia, nausea, swelling, memory deficits, and enlargement of neck.   No facial swelling, hypoactive bowel sounds, and hyporeflexia.

Major Depressive Disorder

Pertinent Positives:  Depression, generalized fatigue, “no energy” and feeling tired all the time, generalized weakness, worsening of depressive symptoms, missed 1 day of work recently because “couldn’t get out of bed” and youngest child with bipolar depression and ADHD and anxiety {Subjective findings}.

Pertinent Negatives:  Denies recent stressful life events, denies suicidal/homicidal thoughts, denies headaches, alcohol and substance abuse.Analysis of the Differential based on the History and Findings.

Cushing’s Syndrome

Pertinent Positives:  Weight gain, generalized weakness {Subjective findings}.  BMI=28.2 {Objective finding}.

Pertinent Negatives:  No complaints of back pain, headaches, and skin changes.  No objective findings of “moon face” appearance, and/or “buffalo hump.”

4. Rank the differential in order of most likely to least likely.

Hypothyroidism (Hashimoto’s thyroiditis)

Major Depressive Disorder

Cushing’s Syndrome

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.Analysis of the Differential based on the History and Findings.

This patient is experiencing some of the symptoms of overt hypothyroidism such fatigue, cold intolerance, increase in weight, dry skin, and constipation (Rugge et al., 2014).  The authors discuss how these nonspecific symptoms can cause a life-threatening complication known as myxedema coma if the patient has untreated hypothyroidism.  It can also increase patient’s risk of coronary artery disease, dyslipidemia, hypertension, obesity, and cognitive problems (Rugge et al., 2014).  In order to rule out thyroid disorder, it is important to screen patient for serum TSH, free T4, and T3 (Rugge et al., 2014).  I would like to order these blood tests for the patient in order to help narrow my differential diagnosis.Analysis of the Differential based on the History and Findings.