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Diagnosis And Treatment Of Hypothyroidism In The Elderly Assignment

Diagnosis And Treatment Of Hypothyroidism In The Elderly Assignment

Subjective:

CC (chief complaint): : “I have a problem in adhering to my medicines and occasionally I feel like quitting them. I don’t really think I need them. I feel like the medicine Squashes me.”

HPI: Petunia Park is a female patient who is 25 years old. She has a history of depression as well as bipolar illness, both of which she controls using  medicines. During the visit today, she grouses about how much she wishes she could stop taking her medicines. The patient has expressed prior thoughts of killing themselves by taking their own life. She reports that she has a hard time falling asleep and that she regularly hears voices when she is awake. She considered her lack of sleep to be transitory and gave a rating of 15 to 21 on a Linkert scale that ranged from 0 to 28Diagnosis And Treatment Of Hypothyroidism In The Elderly Assignment.

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Substance Current Use: Reports alcohol, cigarettes, and marijuana use.

Medical History: Denies any medical history. Reports one hospitalization due to suicide attempt.

 

  • Current Medications: Zoloft 200mg once daily for depression, Seroquel 50mg once daily for bipolar illness, and Risperidone 4mg daily
  • Allergies: NKA
  • Reproductive Hx: LMP: 21/6/2020, last Pap: normal

ROS:

  • GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
  • HEENT: Denies eye pain or vision problems. Denies ear pain or hearing loss. Denies sinus problems or sore throat.
  • SKIN: Denies no rash, lessions, or ecchymosis.
  • CARDIOVASCULAR: Denies chest pain orheart murmurs or palpitations. No swelling
  • RESPIRATORY: Denies shortness of breath or cough. No difficulty in breathing or production of sputum.
  • GASTROINTESTINAL: Denies nausea and vomiting, and no diarrhea or blood in the stool.
  • GENITOURINARY: Denies abnormal bladder function and emptying.
  • NEUROLOGICAL: Denies headaches, dizziness, syncope,or numbness
  • MUSCULOSKELETAL: Denies muscle pain or joint pain.
  • HEMATOLOGIC: No history of anemia
  • LYMPHATICS: Denies enlarged lymph nodes.
  • ENDOCRINOLOGIC: reports being treated for hypothyroidism. Denies night sweats, polydipsia or polyuria.

Objective:

Diagnostic results: no laboratory tests done

Assessment:

Mental Status Examination:

Patient is oriented x4 oriented. She is well-dressed, well-groomed and well-nourished. She cooperative as seen through her willingness to respond to questions and has clear and coherent speech. Her memory is intact. No current suicide ideation, delusions but has had auditory hallucinations and suicide attempt in the past. Her throught process is logical and judgment is intact Diagnosis And Treatment Of Hypothyroidism In The Elderly Assignment.

Diagnostic Impression:

Bipolar disorder: The mental health condition known as bipolar disorder is characterized by extreme shifts in mood. Patients who suffer from this condition often exhibit aggressive behaviors, a propensity to get quickly sidetracked, rushed thinking, and euphoria (Vieta et al., 2018).

Depression: A low mood, along with other negative emotions such as worthlessness, despair, or guilt, is a hallmark of this mental illness. Additionally, the illness manifests itself in suicidal thoughts, and some patients even go so far as to attempt suicide (Tolentino & Schmidt, 2018).

Hypothyroidism: The main symptoms of this disorder include physiological signs, in addition to symptoms such as feelings of sadness, slow thinking processes, exhaustion, and slow movement (Duntas & Yen, 2019). In addition, there is a shortening of attention span, sleep problems, fatigue, excessive daytime sleepiness, mood disturbance, and psychotic features.

Reflections:

I would look into assessing the patient to establish if or not there are any more causes adding to her symptoms. The present diagnosis is apropriate, and it would make it easy to treat her condition.

Case Formulation and Treatment Plan:

The treatment for bipolar disorder, which is a chronic condition, focuses on relieving the symptoms that the patient is currently experiencing. It has a tremendous impact on the emotional state of a person. I will provide this patient with a prescription for a mood stabilizer of 250 milligrams, such as Depakene, to be taken two times per day. If the symptoms continue for more than four weeks after treatment with mood stabilizers, I will recommend that the patient take the antipsychotic risperidone 4 milligrams orally twice daily.

In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

To Prepare
Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Consider patient diagnostics missing from the video:
Provider Review outside of interview Diagnosis And Treatment Of Hypothyroidism In The Elderly Assignment:

Temp 98.2 Pulse 90 Respiration 18 B/P 138/88

Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)

The Assignment
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?

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Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://class.waldenu.edu

References

Duntas, L. H., & Yen, P. M. (2019, October 1). Diagnosis and treatment of hypothyroidism in the elderly. Endocrine, Vol. 66, pp. 63–69. https://doi.org/10.1007/s12020-019-02067-9

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 Criteria and Depression Severity: Implications for Clinical Practice. Frontiers in Psychiatry, 9(OCT), 450. https://doi.org/10.3389/fpsyt.2018.00450

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., … Grande, I. (2018). Bipolar disorders. Nature Reviews Disease Primers 2018 4:1, 4(1), 1–16. https://doi.org/10.1038/nrdp.2018.8 Diagnosis And Treatment Of Hypothyroidism In The Elderly Assignment