Patient Information:
- Initials: S.C.
- Age: 48-year-old
- Sex: Female
- Race: Caucasian
- Insurance: Unknown
Subjective (S):
Chief Complaint (CC):- “Increasing weight despite dieting.”
- S.C. is a 48-year-old white woman presenting with complaints of increasing weight gain over the past 4 months despite dieting. She reports having less energy than usual, decreased interest in her usual activities, and a general slowing down in completing routine tasks. She is dissatisfied with her overall appearance and her inability to lose weight, which has been a source of frustration.
- Denies prescription medications.
- Takes a daily multivitamin for the last month.
- No known drug allergies (NKDA).
- Hypertension (HTN).
- Denies past surgeries.
- Hospitalized for childbirth twice (G2P2).
- None reported.
- Unsure of immunization status.
- No recent influenza or tetanus vaccinations.
- Smoking: Recently quit smoking 4 months ago following the death of her mother from cancer. The patient began smoking at age 18, quit during her pregnancies, but resumed 11 years ago when she returned to work. Before quitting, she smoked 15 to 20 cigarettes per day. She quit smoking without professional help or nicotine replacements.
- Living Situation: Lives with her husband and children.
- Education and Employment: The patient has a college and master’s degree in education and has been employed as a special education teacher for the past 11 years.
- Alcohol/Drug Use: Denies alcohol or illicit drug use.
- Mother: Deceased from cancer.
- Father: Not mentioned.
- No fever or chills.
- Reports a weight gain of 25 pounds in the past 6 months.
- Vision may be less acute, hearing normal.
- No dizziness reported.
- Denies itchiness, rashes, or dryness.
- Denies chest pain, dyspnea on exertion or at night, and swelling in the ankles.
- Denies cough or wheezing.
- Reports a history of “eating binges” beginning at age 16.
- Currently skips breakfast, eats a “normal” lunch, and has dinner with her family.
- Describes evening binges after dinner, including large quantities of food (e.g., Ritz crackers, cheese, doughnuts, Chex mix, and candy).
- Denies abdominal pain, nausea, vomiting, indigestion, or dark/bloody stools.
- None reported.
- Denies loss of consciousness (LOC), numbness, or tingling.
- None reported.
- None reported.
Objective (O):
Vital Signs:- Blood Pressure (BP): Not provided
- Heart Rate (P): Not provided
- Respiratory Rate (R): Not provided
- Temperature (T): Not provided
- Oxygen Saturation (SaO2): Not provided
- Height: Not provided
- Weight: Not provided
- Body Mass Index (BMI): Not provided
- The patient is a Caucasian female who appears her stated age. She has an antalgic gait, is alert, oriented, and cooperative.
- Normal color for ethnicity; cool, dry, and intact skin. No cyanosis, pallor, rashes, or lesions noted.
- No abnormalities in vision or hearing. No dizziness or significant HEENT findings.
- Denies chest pain, dyspnea, and swelling in the ankles. No abnormalities detected in the cardiovascular exam.
- Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi noted.
- The abdomen is soft and non-tender with positive bowel sounds in all quadrants. No organomegaly or masses noted.
- No abnormalities reported.
- The patient is alert and oriented with intact cranial nerves. No focal neurological deficits.
- Normal range of motion (ROM) in all extremities. No tenderness or swelling noted.
- No lymphadenopathy or tenderness.
- The patient is cooperative, with a flat affect and reports dissatisfaction with her appearance. No signs of severe depression or suicidal ideation were noted.
Assessment (A):
Primary Diagnosis:- Hypothyroidism, Unspecified (ICD-10: E03.9): Considering the weight gain, fatigue, and decreased interest in activities despite dieting and exercise, hypothyroidism is a likely diagnosis. Hypothyroidism commonly presents with symptoms such as weight gain, fatigue, and depression.
- Major Depressive Disorder, Single Episode, Moderate (ICD-10: F32.1): The patient’s feelings of worthlessness, decreased energy, and lack of interest in usual activities suggest the possibility of a depressive disorder.
- Obesity (ICD-10: E66.9): Given the recent weight gain and the patient’s BMI, obesity is a consideration that requires further evaluation and management.
Diagnostic Testing:
- Thyroid Function Tests (TSH, Free T4):
- To confirm or rule out hypothyroidism as the cause of the patient’s symptoms.
- Complete Blood Count (CBC):
- To rule out anemia or other hematologic conditions that might be contributing to fatigue.
- Comprehensive Metabolic Panel (CMP):
- To evaluate overall metabolic function, including liver and kidney function, as well as electrolyte levels.
- Lipid Panel:
- Given the patient’s history of HTN and weight gain, a lipid panel would be useful to assess cardiovascular risk.
- Psychiatric Evaluation:
- A full psychiatric evaluation is recommended to assess the severity of depressive symptoms and to develop an appropriate treatment plan.
Plan (P):
- Medications:
- Levothyroxine if hypothyroidism is confirmed.
- Selective Serotonin Reuptake Inhibitor (SSRI) if depressive disorder is confirmed.
- Lifestyle Modifications:
- Continue with smoking cessation support.
- Encourage a balanced diet and regular physical activity.
- Follow-Up:
- Re-evaluate in 4-6 weeks to assess response to treatment and adjust medications as necessary.
- Referrals:
- Referral to a dietitian for weight management.
- Referral to a mental health professional for counseling and support.
- Patient Education:
- Educate the patient on the importance of adhering to prescribed medications and lifestyle changes.
- Discuss the potential long-term complications of untreated hypothyroidism and depression.
