Chief Complaint (CC). Hair falling out and feeling tired
History of the Present Illness (HPI). Chantal, aged 32, came to the clinic and reported experiencing increased fatigue and falling of her hair. Despite her decreased appetite over a year, Chantal’s weight has gained 30 pounds, which became an issue of concern to her. The patient reported having some sleeping problems, feeling cold all the time, itchiness, and nasal congestion through a review of questions. Based on personal observations, Chantal used her fingers to rub and touch the nose bridge. She has also unsuccessfully used OTC Mucinex to enhance her breathing system.
Medications: Mucinex OTC QHS PRN, Lisinopril 20mg PO QD
Allergies: There are no known medical allergies (NKDA)
- Denies environment-related allergies
- Acknowledges seasonal allergies
Past Medical History: After a review of the client’s medical history, it became evident that Chantal had elevated blood pressure. Although linked to hypertension, Chantal reported changes in her vision, frequent nose bleeding, early morning headaches, irregular heartbeats, and buzzing in the ears. The vaccinations are up to date, and she does not report any other lifestyle or chronic illness. She had a flu shot this season and a tetanus booster the previous year. Chantal has no significant history of surgical or medical procedures. However, due to a past motor car accident, Chantal has a pin placed in the ankle.
SOC Hx: Chantal lives in a single-family home with her husband and children. She has a degree in marketing and works in a production company in the region. Although Chantal does not have a regular exercise plan, she enjoys enjoying her hobbies, which include swimming, shopping, and traveling. The patient also denies consuming alcohol, smoking, and drug abuse.
Family History: The father has a history of hypertension, while the other family members have no significant medical account. Her children have never also been diagnosed with any disease. She could not remember any health information about her grandparents.
Review of Systems
General: Chantal has sleep-related issues, weakness, fatigue, and feeling cold all the time. Besides, although she witnessed a decline in appetite, Chantal had gained 30 pounds within a year. She rules out the probability of being depressed.
HEENT:
- Nose: Nasal congestion, sneezing, clear nasal drainage, itchy with sneezing
- Eyes: wear sunglasses for farsightedness. No medical history of photophobia, cataracts, and diplopia. Acknowledges changes in her vision
- Ears: No ear infections, the smell is intact, average bilaterally, no hearing loss, inflamed
- Mouth: No swallowing or chewing difficulties, throat erythema, no detected dental caries
- Neck: No reported pain or masses
- Respiratory: Clear lungs, mild coughing, production of sputum, no reported cases of shortness of breath
- Cardiovascular: No recorded chest discomfort or pressure.
- Skin: Smooth
- Neurological: Morning headaches, dizziness, and no changes in bladder control
- Allergies: No medical history of rhinitis, asthma, and eczema
- Psychiatric: No medical history of mental illnesses
Objective
Vital Signs: BP 141/76; P 72; R 23; T 96.8; Wt 210lbs; Ht 70
General: Chantal is attentive and oriented to time, situations, and places. She is well nourished and presentable.
Gastrointestinal: Regular bowel movements and sounds regarding intensity and quality. No diarrhea, vomiting, and constipation
Pulmonary: Clear lungs
Assessment
- Complete Blood Count- Within normal limits
- Flu Swab-Negative
- Rapid Strep-Negative
Differential Diagnosis
Rhinovirus: Rhinovirus is the most likely diagnosis based on the patient’s symptoms and signs. According to Martinez-Giron et al. (2020), rhinovirus causes common cold-like symptoms that damage the integrity of the epithelial barrier. Specifically, this virus causes numerous features like nasal congestion, sore throat, sneezing, coughs, and frequent common colds. Rhinovirus is a common cause of frequent sneezing, muscle aches, weakness, fatigue, loss of appetite, and frequent headaches. Hence, this will be the diagnosis in Chantal’s case, which shows a more significant number of these symptoms.
Allergic Rhinitis. Allergic rhinitis is another diagnosis route that the practitioner can take to assess Chantal’s medical condition. Chantal presented most of the symptoms linked to this disease. According to Meng et al. (2019), people suffering from allergic rhinitis show various signs, including nasal obstruction, sneezing, rhinorrhea, and pruritus that emerge from inhaled allergens and involve mucosal inflammation. This gesture entails the rubbing of the nose using the index finger. Thus, this medical diagnosis would help ascertain whether Chantal’s symptoms have a connection with this disease or not.
Acute Sinusitis. As the typical result of the common cold, Chantal could suffer from acute sinusitis, thus requiring diagnosis. Sinusitis is the swelling of the tissue liner sinuses resulting from bacteria, viral, and fungal infections or allergic reactions. Some commonly presented sinusitis symptoms are the blockage of the sinus, which in turn causes facial pain, congestion, pressure, cough, and purulent rhinorrhea (Wyler & Mallon, 2019). In other incidences, the disease causes fever, malaise, and headaches. Hence, the practitioner must carry out a sinus CT scan to ascertain the existence and extension of the infection.
Thyroid Disease. Chantal shows many signs and symptoms of thyroid disease. Specifically, the consistent feelings of coldness and the rapid gain of 30 lbs may indicate that she suffers from a thyroid disorder characterized by an underactive thyroid (hypothyroidism). Medical practitioners should thus carry out the necessary tests to confirm or rule out thyroid disorder in this specific case.
Euthyroid Sick Syndrome. The healthcare providers should also carry out all the necessary tests to assess the presence of the euthyroid sick syndrome. Chantal shows some symptoms of this disease, such as fatigue, weight gain, and weakness. According to Braunstein (2022), doctors can confirm the disease’s presence by measuring the thyroid-stimulating hormone levels. Hence, the practitioners should take all the necessary tests to assess whether Chantal could be suffering from this disorder.
References
Braunstein, G. D. (2022). Euthyroid sick syndrome – endocrine and metabolic disorders. Merck Manuals Professional Edition. Web.
Martinez-Giron, R., Van Woerden, H. C., & MartÃnez-Torre, C. (2020). Ciliated nasal epithelial cells damage and human rhinovirus infection: Cytological Findings. Acta Bio Medica: Atenei Parmensis, 91(1), 146.
Meng, Y., Wang, C., & Zhang, L. (2019). Recent developments and highlights in allergic rhinitis. Allergy, 74(12), 2320-2328. Web.
Wyler, B., & Mallon, W. K. (2019). Sinusitis update. Emergency Medicine Clinics, 37(1), 41-54. Web.