Unit 5 Ihuman Maria Ash

Unit 5 Ihuman Maria Ash CC: Fatigue and weight gain Questions Onset: when did the fatigue start? Location: Duration: does this last all day or even after a good night of rest? Characteristics: Aggravating/Relieving ...

Unit 5 Ihuman Maria Ash CC: Fatigue and weight gain Questions Onset: when did the fatigue start? Location: Duration: does this last all day or even after a good night of rest? Characteristics: Aggravating/Relieving: does anything make the fatigue better or worse? Treatment: Have you tried anything to help? When did you first notice the weight gain? How much weight have you gained? Have you tried anything to lose weight? Have you always felt cold when other were warm? Did you just start to notice decreased energy? Do you have pain or swelling in your neck? Radiation to the neck? Previous endocrine problems? Dietary questions (?) Classic early symptoms include fatigue, dry skin, slight weight gain, cold intolerance, constipation, and heavy menses Myalgia, muscle cramps, headaches, and weakness may also be present Later symptoms: very dry skin, coarse hair, loss of lateral eyebrows, alopecia, hoarseness, weight gain, slight impairment in mental ability, depression, decreased libido, and hypersomnia Women require a full menstrual history including date of most recent period, characteristics, and duration More specific to Hashimoto’s-painless thyroid enlargement, neck pain, sore throat, a feeling of fullness in the throat, low grade fever, and exhaustion Mild diastolic hypertension Family history- ask about thyroid problems History of thyroid surgery or radiation in your neck to treat cancer Are you currently on any medication (amiodarone, lithium, interferon alpha, iodine,interleukin-2 or prior chemotherapy can cause these issues) Your text here 1 SOAP NoteMariah AshMariah Ash - 41 year old woman with 65kg complaining of weight gain and fatigue. 1)How can I help you today?- fatigue, it’s getting harder and harder to get through a normalwork today 2)Do you have any other symptoms or concerns we should discus? – Gaining weight, but I swear I am watching what I eat. Bowel habits, I seem to have some constipation Fatigue-onset, When did your fatigue/tiredness start? Do you become more weak or tired with exertion? – Yes, I got tired doing household tasks like gardening. I feel some days I need to take an afternoon nap. I try to keep going through anyway How severe is your fatigue/tiredness?- I guess I’m mostly funcining, but It’s concerning enough that I came in to find out why and ge to the bottom Have you had fatigue/tiredness problems like this before? Has there been any change in your fatigue/tiredness over time?Not much, maybe a bit worse lately Does your fatigue/tiredness improve after a good night’s rest? – Some, but not back to normal Is your fatigue unrelated to physical effort?- I don’t have my normal energy when I wake up, but Ifeel really tired at the end of the day. This is not normal for me. I usually feel energized after teaching classes. I’m the oldest fitness trainer at the gym. Weight gain- When did your problem with weight gain start?- Not sure, I gained most of my weight during the last 3-4 months Constipation- Do you have any pain or other symptoms associated with your constipation? 0 No pain- Have you had constipation problems like this before? No, never-Is there any change in the shape of your stools?- smaller, more compactWhen did your problem with constipation start? –Not sure, at least last 4-6 weeks Are you taking any over-the-counter or herbal emdications? –Not really, just vitamins and calcium, tried fiber supplement for 2 or 3 daysAny diet changes since your last appointment? SOAP NoteMariah AshName: Maria AshAge: 41 yearsSex: FCC:Maria reports to office today with a c/o fatigue, weakness, constipation, temperature intolerance, and unintentional weight gain of 15lbs (6.8kg) over the past 3 months. DDX:Hypothyroidism, Chronic Fatigue Syndrome, Anemia, Depression Patient reports worsening fatigue for about 3 months, and notices unintentional weight gain of 15 pounds. Patient also has constipation, menstrual pried lengthening with irregular menses, dry facial skin. Patient also has elevated diastolicBP (narrowed pulse pressure). She has bradycardia, and has slightly enlarged thyroid (35gm) and hypoactive bowel sounds. HPI:She reports the fatigue and weakness x 3 months are interfering with herwork performance and ADLs. She reports sleeping well but fatigued by midday. Along with generalized fatigue, she report