Directions: You must make a minimum of three substantive contributions on two separate days of the learning week to each discussion topic. Post your response to the discussion question early in the learning week (no later than Wednesday), and then respond to a minimum of two other classmates’ posts. Be sure to respond to any direct comments or questions initiated by the instructor or a classmate. Responses to your classmates should:
Build on something interesting that your classmate wrote.
Explain why and how you see things differently.
Ask a probing or clarifying question.
Share your understanding of your classmate’s posting in your words.
Offer and support an opinion with peer-reviewed sources or industry best practices.
Expand on your classmate’s posting by providing constructive feedback.
The discussion exercise closes on Saturday afternoon.
Jessica, a 41-year-old female presents with a report of insomnia and impaired concentration. She has not slept through the night for approximately 6 weeks and finds that while she can fall asleep readily, she is too restless to stay asleep. At work (she works as an office manager), she is unable to concentrate and has found herself making simple mistakes. Iris is easily fatigued and states that she frequently feels warm and flushed, but she attributes this to “the time of life.” Her menstrual periods have become irregular. Her LNMP was 2 months ago. It lasted 10 days and was slightly heavier than usual. Iris states that she occasionally feels her heart “fluttering” when she feels anxious. She is surprised at this because she has always felt that she coped well with life and was generally happy. “Now, the littlest things seem to bother me, and I feel my heart start to flutter. Oh, the change of life. I have dreaded it. Can you give me something for it?”
Review of Systems (ROS):
General: Reports fatigue, weight changes, concentration issues, insomnia, and night sweats. Denies fever, chills, or pain
Cardiovascular: Reports palpitations and chest pain.
Respiratory: Reports shortness of breath.
Gastrointestinal: Reports changes in appetite and bowel habits.
Genitourinary: Reports changes in menstrual cycle, urinary symptoms.
Endocrine: Reports heat intolerance and sweating.
Neurological: Reports headaches and dizziness. Denies weakness or tremors.
Psychiatric: Reports mood changes, depression, anxiety, and increased stress levels.
Elimination: She denies constipation or loose stools.
Past medical history: Hospitalization for a Cesarean section without complications 15 years ago. She also had a hemorrhoidectomy 7 years ago without complications.
Family medical history: Jessica has a husband and one son who are alive and well. Her mother, age 67, has stage 1 Alzheimer’s disease and hypothyroidism. Her father has diabetes mellitus type 2 and a history of colon cancer. Both are alive.
Social history: She lives with her husband and son and states that she is happily married and comfortable financially. She stopped using any form of birth control since her periods became irregular 6 months ago. She is a smoker, about 1 pack per day for 20 years. She drinks 2-3 cups of coffee or tea a day and admits to 2 glasses of wine at night to try to relax her and sleep. She takes no medications and has been generally healthy.
PE:
The patient appears anxious but is pleasant and cooperative. Her weight is 136 lbs; She is 5’8”, she comments that this is 10 lbs. less than the last time she checked her weight 3 months ago. Oral temperature is 100 degrees Fahrenheit. BP is 148/94. HR is 96 and regular. Respirations are 12 and regular.
HEENT: Hair is shiny and soft. No exophthalmos is observed. There is no lid lag or eye retraction. Sclerae are clear and conjunctivae are without injection. PERRLA and EOMs are intact. CNs II–XII are grossly intact. There is no cervical lymphadenopathy. Trachea is midline. The thyroid is mildly palpable with a bruit. There are no nodules.
Skin: The patient’s skin is warm, no rashes or dryness.
Cardiac: HR: 96; RRR: S1/S2; no murmurs, clicks, gallops or rubs.
Pulmonary: Lungs are clear bilaterally.
Abdomen: Soft without tenderness or distention. No organomegaly, no bruits. Bowel sounds are active throughout.
Neurologic: There are no tremors. Sensation and proprioception are grossly intact. DTRS are +3 in upper extremities and lower extremities. Romberg is negative. RAMs are negative. Gait is steady.
Musculoskeletal: FROM and strength of 5/5 in all extremities.
Questions:
What additional information would you gather from the patient’s history to help with the differential diagnosis?
What specific physical examination techniques and findings would be most relevant for this case?
Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?
What are the most likely differential diagnoses, and why?
What is the most appropriate plan of treatment, including pharmacologic and non-pharmacologic interventions?
What is a likely diagnosis if this patient returns with severe tachycardia, confusion, vomiting, diarrhea, high fever, and dehydration?
What if this patient’s lab results return and the TSH is low with normal results for free T4 and T3?
What additional patient education is important for Jessica, and how does that impact her diagnosis and management of the diagnosis? What is the plan for follow-up care?
Are any referrals needed, and if so, to which specialists?
Are there any standardized guidelines that should be used to assess and treat this case?
What are the potential complications or long-term health implications of Jessica’s current condition, and how might they be prevented or managed?
How would you involve Jessica in shared decision-making regarding her care plan?
What are the key patient education points to ensure Jessica’s understanding of her condition and adherence to the treatment plan?
What are the most important aspects of follow-up care for Jessica, and how would you ensure continuity of care
