Review of History and Physical Findings
The client is a 56-year-old Caucasian female who presents with complaints of fatigue that reportedly began 2 to 3 months prior to her visit. She reports that the fatigue is generalized and constant in duration, and has been progressively worsening since onset. The client reports feeling tired all the time and lacking the energy to do anything‘she could normally do’despite sleeping eight hours per night. No relieving factors were identified, although the client reports exertion as a possible aggravating factor. The client is married, has two grown kids, and works as a full-time office manager in an internal medicine office. She reports missing a day of work two weeks ago because she ‘couldn’t get out of bed’. She denies pain, fever, chills, or recent illnesses, but has gained 5 pounds since the last visit 6 months ago.

The client denies visual changes, ear pain, rhinorrhea, ST, or history of sleep apnea, but admits to having tonsillectomy as a child. There is no evidence of lymph node tenderness, cough, wheezing or chest pain, and the client denies nausea, vomiting, diarrhea, and constipation. A review of skin and endocrine system shows that the skin is dry, hair is coarse and there is no evidence of polyuria, polydispia, or cold intolerance. The client, however, reports worsening depressive symptoms, suicidal or homicidal thoughts, and generalized muscle weakness or intermittent cramping. The client’s PMH includes hypertension, depression, and postmenopausal status, and a history of iodine dyes, allergies, and tonsillectomy. She denies cigarette or drug use, but admits to taking 1 to 2 glasses of wine every month. Family history is indicative of mental illness, hyperlipidemia, hypertension, and seasonal allergies.

The physical exam shows the client to be alert, oriented, and cooperative, with head, eyes, ears, nose, cardiopulmonary, and abdomen examinations all normal. The client’s mood is appropriate and pleasant, with the neurology exam showing normal reflexes at the biceps and traceable reflexes at the knees and ankles.

Differential Diagnosis

Three differential diagnoses could be deduced from the subjective and objective information: hyperthyroidism, hypothyroidism, and thyroid cancer. Hyperthyroidism occurs when the thyroid gland overproduces the thyroid hormones T3 and T4, leading to an up-regulation of metabolism that manifests in an increase in heart rate and total body heat production (Dunphy et al., 2019). The clinical presentation includes a combination of anxiety, nervousness, insomnia, weight loss, palpitations, heat intolerance and fatigue (Dunphy et al., 2019). Patients may also report exertional dyspnea, diarrhea, menstrual irregularities, lower extremity edema, exercise intolerance, musculoskeletal weakness, and weight loss even in with increasing appetite (Dunphy et al., 2019).

Hypothyroidism results from the underproduction of thyroid hormones and has the effect of slowing down metabolic processes and many other bodily functions in the same way as thyroid failure (Dunphy et al., 2019). Risk factors for thyroid failure include radiation treatment, use of iodine or lithium, presence of anti-thyroid antibodies, and a family history of thyroid disease (Dunphy et al., 2019). Fundamental symptoms of hypothyroidism include heavy menses, constipation, cold intolerance, slight weight gain, dry skin, and fatigue (Dunphy et al., 2019). Depending on the duration of illness, the patient may also report very dry skin, hypersomnia, continued weight gain, depression, and slight impairment in mental ability (Dunphy et al., 2019). The primary symptom of thyroid cancer is a painless nodule or lump in the neck, although the patient may also complain of neck tightness, difficulty swallowing, hoarseness, and swollen lymph nodes (Dunphy et al., 2019). Depending on the duration of illness, the patient may also report neck pain (Dunphy et al., 2019).

Thyroid cancer is the least likely diagnosis of the three. The...…al., 2019).

Referral

Refer the client to a nutritionist for dietary advice and lifestyle changes as her current BMI is indicative of overweight.

Problem List for the Client

The following problems are evident from the evaluation conducted on the client:

i) The client is overweight, with a BMI of 28.2

ii) The client has a history of hypertension and tonsillitis

iii) The client’s family has a rich history of hyperlidemia, hypertension, seasonal allergies, and mental illness, particularly bipolar disorder

iv) The client faces a lot of stress as she has to work full-time and still take care of her two children undergoing treatment for bipolar disorder and seasonal allergies

Changes to Treatment Plan

The FDA advises that the therapeutic effect of LEVO-T may not be attained for 4 to 6 weeks (FDA, 2017). As such, there may be a need for the clinician to wait at least 4 weeks before making any changes to the treatment plan. During this time, the client is to be closely monitored for adverse effects, particularly cardiac adverse reactions resulting from over-treatment with LEVO-T (FDA, 2017). If the client reports no serious adverse effects by the end of four weeks, the dosage of LEVO-T could be titrated upwards towards the maximum of 75mcg daily in view of the client’s TSH levels then. If cardiac symptoms are reported before 4 weeks, however, the clinician could consider reducing the dosage to 25mcg daily (FDA, 2017). Treatment with the SSRI Zoloft is to be sustained for a minimum of 6 weeks, after which the clinician will assess the client’s progress and determine whether to continue.

Follow-Up

Given the risks associated with over-treatment using LEVO-T for postmenopausal clients, the clinician needs to organize a review in 4 weeks to measure TSH levels and check for any cardiac-related adverse effects before deciding whether or not…