Full Answer Section

Slide 2: CC: “I’m here to get some help with losing weight, but I also have my thyroid condition.”

• Title: Chief Complaint
• Content: “Patient states: ‘I’m here to get some help with losing weight, but I also have my thyroid condition.'”
• Image Suggestion: A close-up, empathetic image of a patient speaking with a healthcare provider.
• Citation: (No citation needed for the chief complaint itself, but subsequent information will be cited).

Slide 3: HPI: History of Present Illness

• Title: History of Present Illness
• Content:
  • 51-year-old female presenting to establish care.
  • Weight Loss Request: Reports a gradual weight gain of approximately 15 pounds over the past 1-2 years. Expresses frustration despite attempts at diet and exercise (details vague, needs further exploration during assessment). Feels this weight gain is impacting her energy levels and overall well-being. Actively seeking pharmacological intervention to aid weight loss.
  • Thyroiditis: Diagnosed with Hashimoto’s thyroiditis in 2013. Reports being on levothyroxine since diagnosis. States she generally feels “stable” on her current dose but occasionally experiences fatigue and mild cold intolerance. Reports recent (last 3-6 months) increased fatigue despite consistent levothyroxine use, which she attributes partially to her weight gain. Denies recent neck pain, swelling, or difficulty swallowing.
• Image Suggestion: A timeline visually representing the patient’s health history with key dates for diagnoses and current concerns.
• Citation: (To be cited on subsequent slides if specific clinical practice guidelines or research is referenced regarding symptom presentation).

Slide 4: ROS: Review of Systems

• Title: Review of Systems
• Content (Pertinent Positives and Negatives):
  • General: Reports increased fatigue (as mentioned in HPI), denies fever, chills, night sweats.
  • HEENT: Denies changes in vision, hearing, or nasal congestion. No sore throat or hoarseness.
  • Cardiovascular: Denies chest pain, palpitations, shortness of breath at rest.
  • Respiratory: Denies cough, wheezing.
  • Gastrointestinal: History of IBS (diagnosed 2006), reports occasional abdominal discomfort and bloating, but no recent significant changes.
  • Genitourinary: Reports no changes in urinary frequency or pain.
  • Musculoskeletal: Denies joint pain or swelling.
  • Neurological: Denies headaches, dizziness, paresthesias.
  • Endocrine: Positive for symptoms consistent with hypothyroidism (fatigue, cold intolerance – occasional). Denies polyuria, polydipsia.
  • Psychiatric: Reports feeling somewhat down due to weight gain and fatigue but denies symptoms consistent with major depression or anxiety disorder.
  • Skin: Reports no changes in skin texture or hair loss beyond what she attributes to her thyroid condition.
• Image Suggestion: An infographic outlining the major body systems with highlights indicating positive and negative findings relevant to the case.
• Citation: (To be cited on subsequent slides if specific clinical practice guidelines or research is referenced regarding symptom relevance).

Slide 5: Relevant History

• Title: Relevant History
• Content:
  • Past Medical History:
    • Hashimoto’s thyroiditis (diagnosed 2013), currently managed with levothyroxine.
    • Irritable Bowel Syndrome (IBS) (diagnosed 2006), managed with dietary modifications.
  • Past Surgical History: None reported.
  • Social History: Lives with her spouse. Works a sedentary office job. Reports attempting to exercise 2-3 times per week (walking). Non-smoker, drinks alcohol occasionally (1-2 glasses of wine per week).
  • Family History: Mother has hypothyroidism. No reported family history of obesity, diabetes, or other significant endocrine disorders.
• Image Suggestion: A visual representation of the patient’s past medical, social, and family history using icons and brief text.
• Citation: (To be cited on subsequent slides if specific clinical practice guidelines or research is referenced regarding the relevance of these history points).

Slide 6: Allergies

• Title: Allergies
• Content: Reports no known drug allergies (NKDA). Reports no known environmental or food allergies.
• Image Suggestion: A simple “Allergy Free” icon or a medical alert symbol with a strikethrough.

Slide 7: Current Medications

• Title: Current Medications
• Content:
  • Levothyroxine 100 mcg orally once daily (reports taking consistently).
  • Occasional use of over-the-counter antispasmodics for IBS symptoms as needed.
• Image Suggestion: Pill icons representing the patient’s current medications.
• Citation: (No citation needed for listing medications, but interactions would be cited on the management slide).

Slide 8: Physical and Psychological Assessment

• Title: Physical and Psychological Assessment
• Content:
  • Physical Exam:
    • General: Well-appearing female, alert and oriented, no acute distress.
    • Vitals: BP 130/82 mmHg, HR 78 bpm, RR 16 bpm, Temp 98.6°F (37°C), SpO2 98% on room air, BMI 28.5 kg/m² (Overweight). Weight: [Record Actual Weight], Height: [Record Actual Height].
    • Skin: Warm and dry, normal turgor. No obvious rashes or lesions.
    • HEENT: Normocephalic, atraumatic. Eyes: PERRLA. Oral mucosa moist and pink. Neck: Thyroid palpable, slightly firm, no nodules appreciated, no tenderness. No lymphadenopathy.
    • Cardiovascular: Regular rate and rhythm, S1 and S2 auscultated, no murmurs, rubs, or gallops.
    • Respiratory: Clear to auscultation bilaterally.
    • Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds.
    • Neurological: Grossly intact.
    • Extremities: No edema, full range of motion.
  • Psychological Assessment:
    • Patient reports feeling somewhat down due to weight and fatigue but denies anhedonia, significant changes in appetite or sleep, or suicidal ideation. Affect congruent with reported mood.
• Image Suggestion: A composite image showing standard physical assessment techniques (e.g., blood pressure cuff, stethoscope).
• Citation: (To be cited on subsequent slides if specific clinical practice guidelines or research is referenced regarding assessment findings).

Slide 9: Differential Diagnosis

• Title: Differential Diagnosis
• Content:
  • 1. Suboptimal Control of Hashimoto’s Thyroiditis (ICD-10: E06.3):
    • Rationale: Patient’s history of Hashimoto’s, recent increase in fatigue despite levothyroxine, and occasional cold intolerance suggest potential for suboptimal thyroid hormone levels. Hypothyroidism is a known cause of weight gain and fatigue.
    • Citation: [Reference 1: Recent clinical practice guideline for the management of hypothyroidism, e.g., from the American Thyroid Association or European Thyroid Association, within the last 5 years].
  • 2. Medication-Induced Weight Gain (ICD-10: T36-T50 with 6th character 5 for adverse effect):
    • Rationale: While levothyroxine itself is not typically associated with weight gain, other potential over-the-counter medications or supplements the patient may be taking could contribute. Further questioning is needed, but it remains a possibility.
    • Citation: [Reference 2: A recent peer-reviewed article discussing medications that can cause weight gain, within the last 5 years].
  • 3. Primary Obesity (ICD-10: E66.9):
    • Rationale: The patient’s BMI of 28.5 kg/m² falls into the overweight category, and her reported weight gain over the past 1-2 years, despite attempts at lifestyle modifications, makes primary obesity a likely contributing factor to her concerns.
    • Citation: [Reference 3: A recent clinical practice guideline for the management of obesity or overweight, e.g., from the Obesity Society or American Heart Association/American College of Cardiology/The Obesity Society, within the last 5 years].