| Outline Subjective data.
Identify data provided in your chosen case and any additional data needed. |
Outline
Objective findings.
Identify findings provided in your chosen case and any additional data needed. |
Identify diagnostic tests, procedures, laboratory work indicated.
Describe the rationalefor each test or intervention with supporting references. |
Distinguish at least three differential diagnoses.
Describethe rationales for your choice of each diagnosis with supporting references. |
Identify appropriate medications, treatments or other interventions associated with each differential diagnosis.
Describe rationales and supporting references for each.
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Explain key
Social Determinants of Heath (SDoH) for your chosen case. |
Describe collaborative care referrals and patient education needs for your chosen case.
Describe rationales and supporting references for each.
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| · Her last menstrual period was two weeks ago and states that it was heavier than normal as she had to change a tampon every hourly in the first two days.
· She states she is not using any contraceptive as she and her husband want to conceive.
· She attained menarche at 10 years and has had a normal cycle length of five days until three months ago.
· She denies history of sexually transmitted illness and pregnancy.
· She is allergic to penicillin and is currently taking prenatal vitamins.
· She lives with her husband and is a housewife after being forced to quit her job after marriage.
· She drinks one or two glasses of wine a day but does not smoke.
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· Vitals: BP-109/66, Resp. rate 16, temperature 97.3F, weight 101lbs, height 64’’, BMI 17.3
· General examination reveals a withdrawn patient who is orientated, fails to make eye contact.
· She also appears disheveled and underweight.
· Her skin is warm, dry, and intact, but there is a bruise in the inner thigh.
· An abdominal examination reveals a soft and non-tender abdomen with four bowel sounds were heard.
· The pelvic examination revealed:
a) Normal hair distribution with absent lesions and erythema on the external genitalia.
b) Speculum examination findings were non-significant.
· The breast examination was normal.
Additional objective data I would have needed is:
a) If there is presence of pallor and petechial hemorrhages on mucosal sites.
b) A detailed mental status examination.
c) A neck examination (Zamwar et al., 2023). |
· Complete blood count to evaluate platelet and red blood cell count due the associated period of menorrhagia (Jain et al., 2023).
· Thyroid function tests to detect for any thyroid abnormalities contributing to some of the patient’s signs and symptoms.
· Coagulation screen as defects in clotting factors are associated with menorrhagia.
· Hamilton Depression Rating Scale (HDRS) to screen for depression.
· A pelvic ultrasound to detect for any pelvic abnormalities that may cause menorrhagia. |
Maxine has been experiencingabnormal uterine bleeding (AUB) for the last three months which may have resulted from:
1. Major Depressive Disorder (MDD)
· MDD is a psychiatric condition characterized by mood changes and somatic symptoms including self-neglect, social withdrawal, and loss of concentration and eye contact.
· It often results after a significant loss, such as unemployment or when there is change in one’s personal life, including marriage and domestic abuse (Karrouri et al., 2021).
· In addition, some patients with MDD may experience appetite loss and unintentional weight loss as seen in Maxine where she has lost more than 21 lbs in the last year while some may experience menstrual irregularities due to increased stress levels (Jain et al., 2023).
2. Hypothyroidism
· Hypothyroidism is a condition characterized by production of low levels of thyroid hormones T3 and T4 which results in alteration in metabolism and function of various organ systems (Zamwar et al., 2023).
· As a result, female patients with hypothyroidism often experience menstrual irregularities, such as menorrhagia, dry skin, hair loss, cold intolerance, and mood symptoms including depression.
3. Thrombocytopenia
· Thrombocytopenia is a condition characterized by low platelet counts and may be caused by heavy alcohol consumption and poor nutrition.
· Thrombocytopenia is a common cause menorrhagia and polymenorrhea (Gerema et al., 2023).
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MDD
· I would prescribe antidepressants like sertraline 50 mg PO OD or Prozac 20 mg PO OD (Karrouri et al., 2021).
Hypothyroidism
· I would prescribe Levothyroxine 75 mcg PO OD ((Zamwar et al., 2023).
Other treatment plans would include:
· I would also involve a nutritionist to plan an appropriate diet for Maxine, thus correct her low BMI.
· I would refer the patient for psychotherapy for couple or cognitive-behavioral therapy (CBT) (Karrouri et al., 2021). |
· Health outcomes in MDD are associated with SDoH in the patient’s life.
· In this case, it is crucial to note that Maxine’s unemployment status predisposes her to financial instability, which may limit her heath seeking attitude (Remes et al., 2021).
· In addition, she is exposed to domestic violence while at home where she lives with her husband, thus negatively impacting her physical and mental health.
· Maxine’s coping skills to the current life stressors may also indicate loneliness which limits her social engagement and awareness of supportive programs crucial in aiding her recovery. |
· Gynecologist
A gynecologist review is crucial as they would help diagnose the specific cause of the AUB (Gerema et al., 2023).
· Endocrinologist
A review from a gynecologist is crucial to exclude any possible hypothyroidism (Zamwar et al., 2023).
· Psychiatrist and Psychologist
The two would be crucial to tailor the patient’s treatment, medications, and manage a possible alcoholism diagnosis. They may also offer psychological support for the patient and provide alternative coping skills (Lopes et al., 2021).
Patient Education
·I would educate Maxine about menstrual abnormalities, the importance of monitoring her periods, and encourage iron supplements to prevent anemia due to polymenorrhea and menorrhagia.
·I would also educate Maxine on hypothyroidism and hyperthyroidism and inform her on any other associated symptoms.
·I would also educate her on MDD and anxiety symptoms and provide appropriate information she can use to manage the symptoms (Christensen et al., 2020).
·I would also provide nutritional advise to help improve her BMI to a normal weight and discourage her from heavy alcohol consumption.
·I would also educate her on available social support services who provide services to persons facing domestic abuse.
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