The patient’s CC was that she felt hot, weak and shaky, which she stated was probably due to her throwing up so much. She had to be assisted to the hospital by her roommate. Important questions to ask were when each of the symptoms started, which she responded to all of them by saying they started when she had the flu, which she reported having last week. It is important to ask about her physical ability to exercise. She reported that she used to run two to three miles a day, but that now she felt unable to walk up a flight of stairs without getting winded and her heart starting to pound. Changes in weight and eating habits are important to address. The patient reported that she used to eat all of the time, but she is unable to stop from losing weight. Currently, she notes that the idea of food or alcohol makes her nauseous. She reported that she had given up being vegetarian, and had changed to be pescetarian in order to get more protein. She also reported that she felt dehydrated, and that she constantly felt as though she needed water.
To assess her physical condition, it is important to ask whether she has a fever to accompany feeling hot, which she responded to by saying she’s had a fever of 101. She also reported that she used to be cold all the time, but that now she had to keep all of the windows open. To assess if there were any additional pain with the patient’s symptoms, it is important to ask if she had any pain. She reported having no pain. It is also important to ask about potential infections, and through a series of questions, the only change recently was that she had skipped her last period and that her menstrual cycle had lightened from five days on average to four. She noted that she has always been regular, but that skipping recently caused an argument between her and her boyfriend, which caused them to break up.
The patient repeatedly was crying during the interactions. Another series of questions that are important regard her overall mood lately, and whether she had anxiety, mood changes, or was experiencing depression. She noted that everything lately has set her on edge, and that she is angry and irritable, but that she was not depressed. Asking about any medication is an important set of questions as well. The patient reported that she didn’t like taking medications, but that she did take a multi vitamin, calcium tablets, Claritin for seasonal allergies, and Tylenol to help with her flu last week. Finally, it is important to ask after where she may have contracted her initial flu. She reported that she had not traveled recently, that she was up to date on all of her immunizations, but that she did not receive the flu shot, which she now regretted. She also said that she believed the flu was passed to her from one of her classmates on campus. She was asked about her sexual history, her family history, any drug use, and any childhood or adult illnesses or hospitalizations. Finally, the patient routinely answered that she didn’t know, or that she couldn’t remember answers to specific questions. Follow up questions as to whether she suffered memory loss or confusion were negative.
The Components Of The Physical Exam
The components of the physical exam for this case that are important to review are respiratory, skin/hair/nails, as the patient mentioned that they had become white and brittle, cardiac exams to address her reported heart flutters, neurologic exams and endocrine exams. Thyroid enlargement, temperature, and cough should be three main areas looked at, following what was learned through the initial assessment. The positive findings of the physical exam that were mentioned in the initial assessment were that the patient had a fever, heat intolerance, insomnia, irritability and agitation. The physical examination also found additional pertinent positive findings, which included tachycardia, tachypnea, lung crackles, as well as shakiness in the hands and sweating in both the skin and palms.
The differential diagnosis to be considered with this case study are hyperthyroidism, pneumonia, and Grave’s disease. The final diagnosis is hyperthyroidism, as well as pneumonia. Hyperthyroidism results from excessive T4 and T3 levels, with symptoms including, “confusion…nervousness and tremor, emotional lability…heat intolerance, weight loss (with increased appetite) [and] palpitations” (Bucurescu, 2015). Pneumonia was brought on by the recent flu, which then made the patient’s undiagnosed hyperthyroidism worse.
References
Bucurescu, G. (2015). Neurological manifestations of Thyroid disease in clinical presentation”. Medscape, December 17, 2015. Retrieved March 22, 2017 from http://emedicine.medscape.com/article/1172273-clinical
