Recent Case

Patient Information:

Betty Thompson is a 45-year-old African American female. She works as a school teacher and lives with her husband and two teenage children.

Subjective CC (chief complaint):

Betty reports irregular periods and hot flashes for the last six months. She has also been feeling unusually tired recently.

HPI: The key symptoms reported by Betty are irregular menstrual cycles, hot flashes, and fatigue. These symptoms can indicate the onset of perimenopause.

Current Medications: Betty is currently taking multivitamins and calcium supplements.

Allergies: Betty has an allergy to shellfish.

PMH: No history related to surgery or immunization recorded.

Soc & Substance Hx: She reports no tobacco or drug use and consumes alcohol socially. She exercises moderately and follows a balanced diet.

Fam Hx: Her mother had breast cancer diagnosed at age 50.

Surgical Hx: Betty underwent an appendectomy at age 20.

Mental Hx: No history of mental illnesses.

Violence Hx: No history of violence reported.

Reproductive Hx: Betty has two children and has been using condoms for contraception. She has never had an STD.

Objective Physical Exam: Betty's vital signs are within normal limits. Her physical examination is mostly unremarkable, except for mild pallor.

Diagnostic results: A complete blood count could be done to evaluate her fatigue and mild pallor for any signs of anemia.

Assessment Differential Diagnoses

1. Perimenopause: Given Betty's age and symptoms, perimenopause is the most likely diagnosis. Perimenopause typically starts in a woman's 40s and is marked by changes in menstrual cycle and symptoms such as hot flashes (Harlow et al., 2012).

2. Anemia: The fatigue and pallor could indicate anemia, which might be related to her irregular periods (Napolitano et al., 2016).

3. Hyperthyroidism: Irregular periods, hot flashes, and fatigue can be symptoms of hyperthyroidism, although this is less likely without other symptoms like weight loss or palpitations (De Leo et al., 2016).

4. Pregnancy: Despite the lower likelihood due to her age and use of contraception, the changes in her menstrual cycle and fatigue could be signs of pregnancy (Barber et al., 2022).

Plan

Betty should undergo further testing, including a complete blood count to evaluate for anemia, and thyroid function tests to rule out hyperthyroidism. Additionally, a pregnancy test should be done to rule out pregnancy. If her symptoms persist and no other causes are found, she could be experiencing perimenopause.

Betty could be counseled on lifestyle modifications to help manage her symptoms, such as maintaining a healthy diet, regular exercise, and adequate sleep. If her symptoms are severe, hormonal therapy could be considered, although the risks and benefits must be weighed carefully given her family history of breast cancer.

Follow-up is needed to evaluate the results...…that they align with the patient's values. Plus, if the patient has any special preferences or needs, or has some lifestyle choices that need to be taken into consideration, the involvement of the patient helps to bring all this to the fore. It is much better for this reason to the patient involved in the treatment option, and it also means that the patient is more likely to adhere to the treatment as well when she is involved in the decision-making. Essentially, the healthcare provider's role is to provide medical advice based on their expertise and the current evidence, while the patients role is to express her personal predilections and principles, i.e., what she wants, what she is comfortable with, and what she is willing to do for her health. This collaboration ensures a treatment plan that not only is medically sound but also respects the patients autonomy and individual circumstances (Pomey et al., 2015).

Lastly, since Betty is possibly transitioning into perimenopause, providing more extensive counseling about what to expect during this period, common symptoms, and management strategies could be beneficial. For example, for this type of patient, discussing common changes like mood swings, sleep disturbances, and changes in sexual desire can better prepare her for this new phase in her life…