Question B.N, a 32-year-old female presents to your clinic with complaints… B.N

Question B.N, a 32-year-old female presents to your clinic with complaints… B.N, a 32-year-old female presents to your clinic with complaints of increased fatigue over the past 5 months. She further reports weight gain, constipation, and cold intolerance. ” I often feel cold even when my boyfriend or coworkers complain of heat” ” My boyfriend keeps saying I need to see the doctor” . Menstrual period is regular, but became heavy the past 3 months, and she believes she has never had it this heavy. She denies any dizziness, dyspnea, syncope, abdominal pain, nausea or vomiting, chest pain or headache. Denies hematuria, dysuria, urinary frequency or urgency. Denies anhedonia and sleeps 8-9hours a night. Last medical checkup was a year ago. LMP was 2 weeks ago; sexually active-in a heterosexual relationship. No contraceptive use. Denies vaginal bleeding other than her period. Last WWE was one yr ago normal, including pap smear result. Past Medical History: Asthma(childhood), migraine headaches, Borderline HTN Medication History: Ibuprofen 200mg-1-2 tabs prn for headache. Family Medical History: Mother-DM II and Grave’s disease; Father: HTN; 2 brothers-all healthy. Drug Allergy: NKDA Social History: Smokes 1 pack per day of cigarette; drinks 1-2 bottles of beer 2-3 evenings per week. Denies illicit drug use. Occupation: Works in a departmental store-works 4-5 days a wk. Physical Exam Gen: Somewhat lethargic, otherwise in no acute distress V/S: BP: 132/88, HR: 82, T: 97.8, RR: 12, 02 sat: 96%(room air) wt: 178lbs, Ht: 65inches HEENT: Conjunctiva slightly pale; thyroid gland slightly enlarged, neck is supple Lymphatic system: No lymphadenopathy CV: Normal S1& S2, rhythm regular Resp: Clear to auscultation bilaterally. No use of accessory muscles Abd: Soft, non-distended, non-tender, bowel sounds + and normal X 4 quadrants, no masses palpated. Neuro/Psych: alert and oriented X 3. CN II-XII grossly intact. Good eye contact, speech clear and goal oriented. Affect normal. GU: WNL, guaiac negative Skin: Nailbeds somewhat brittle and pale.Diagnostic Tests: Labs B.N’s values Potassium 4.0 Sodium 142 Cl 99 HC03 28 BUN 22 RBC 3.5 Hgb 11.8 Hct 32 MCV 77 MCHC 26 WBCs 9,000 Platelet 17,000 Ferritin 8 Free T4 0.5 TSH 20 Case Questions: 1. What is/are the diagnoses: Support with literature evidence and interpretation of data presented in the case study. Discuss the pathophysiology of the selected diagnosis. 2. Present and briefly discuss(rationale) 3 differential diagnoses for this patient. 3. Discuss plan of care for this patient-pharmacological, education, referral, and need for further diagnostic testing if any: Support plan of care/intervention with literature evidence. 4. What labs would you order to monitor this patient, and how often? Support your response with literature evidence Health Science Science Nursing NURS MISC Share QuestionEmailCopy link Comments (0)

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