Identifying Data:
Full Name: Mr. B
Address: Ozone Park, NY
Date of Birth: January 3rd, 1994
Date & Time: June 4th, 2020
Location: Queens Line Medical Center, Ozone Park, NY
Religion: Muslim
Source of Information: Self
Source of Referral: Self
Mode of Transport: Self
Chief Complaint: “I’ve been losing weight for the past 2 months”.
HPI:
Mr. B is a 26-year-old male patient with a PMH of hyperthyroidism and anxiety is here today due to complains of recent unintentional weight loss. Patient states that he first noticed weight loss last month when his “tight” shirts were now to big on him. Regardless of consuming more food and never skipping meals, Mr. B continued to lose weight and reported that in the past two months he has lost at least 8 or more lbs. Patient states that his appetite is normal and still loves to eat his favorite foods. Patient states that he also feels tired and fatigue when he comes from school and lays in bed for the rest of day. Patient denies trouble sleeping and even when he sleeps for 8-9 hrs he still wakes up tired. Patient denies nausea, vomiting, abdominal pain syncope, fever, chills, cough, diarrhea, constipation, headache, hematemesis, excessive sweating, and heat intolerance.
Past Medical History:
Present illnesses – Hyperthyroidism x 2 years; Anxiety x 4 years
Past medical illnesses – none
Hospitalizations: none
Immunizations- Up to date.
Screening tests and results- positive anxiety screening test 4 years ago.
Past Surgical History:
Denies past surgical history.
Medications:
Methimazole 15 mg orally per day for hyperthyroidism, last dose 2 years ago. Patient stated that he likes to be self-medicated and does not believe in taking medications. Patient stated he only took methimazole for the first 2 weeks and stopped.
Fluoxetine (Prozac)10 mg orally once a day in the morning for anxiety, last dose couple months ago. Patient stated he only takes fluoxetine when he can’t smoke marijuana.
Allergies:
Denies drug, environmental or food allergies.
Family History:
Denies family history of cardiovascular diseases, cancer, strokes.
Social History:
Admits to smoking marijuana almost every other day and states that it helps him concentrate better and does not feel as anxious when he’s “high”.
Patient states he mostly feels anxious when he’s with his family. Mr. B states his family puts a lot of pressure on him to finish school and he gets into a lot of fights with his father whenever he stays out for too long. His family does not know he smokes marijuana and states that he’s very anxious that his family will find out one day and “all hell will break loose”.
Denies tobacco use, alcohol consumption and any other illicit drug use.
Travel- Has not recently traveled anywhere.
Sexual Hx- Not sexually active. No past history of STD’s, HIV or any other sexually transmitted diseases.
Review of Systems:
General: Patient states he has noticed recent unintentional weight loss in the past 2 months. Patient also states he feels tired and fatigue when he comes from school. Denies loss of appetite, fever, or night sweats.
Eyes – Patient states he recently noticed problems with his vision. He reports episodes of diplopia (double vision) but thinks his eyesight is just bad and just needs glasses. Currently he reports his eyesight is normal. Denies lacrimation, pruritis, or photophobia. Last eye exam 2018 -pt does not wear glasses or eye contacts.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies chest pain, palpitations, edema/swelling of ankles/feet, syncope, known heart murmur.
Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Genitourinary system – Patient denies nocturia, urinary frequency or urgency, oliguria, polyuria, dysuria, incontinence.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Patient states he feels anxious, especially with his family. Patient states his family puts a lot of pressure on him and gets into fights with his father. Denies mood changes, depression, sadness, OCD.
Physical exam:
General: Pt is alert and oriented x3, neatly groomed, slightly distressed, and worried but responsive to verbal commands.
Vital Signs: BP: R L
Seated 125/85 120/75
Supine 130/80 130/80
R: 18/min unlabored P: 90, regular
T: 98.6 degrees F (oral) O2 Sat: 99% Room air
Height 5 feet and 11 inches Weight 145 lbs. BMI: 20.2 (normal weight)
Eyes – symmetrical OU; no evidence of strabismus, exophthalmos, or ptosis; sclera white.
conjunctiva & cornea clear.
Visual acuity (uncorrected – 20/40 OS, 20/20 OD, 20/20 OU).
Visual fields full OU. PERRLA, EOMs full with no nystagmus
Fundoscopy – Red reflex intact OU. Cup: Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.
Thyroid – Thyromegaly noted on palpation. Non-tender; no palpable masses; no bruits noted.
Thorax & Lungs:
Chest– symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP 2:1, non-tender to palpations.
Lungs– Clear to auscultation and percussion bilaterally. Chest expansions and diaphragmatic excursions symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: No tenderness to palpation. JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: No hernias noted. Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Assessment:
Mr. B is a 26-year-old male patient with a PMH of hyperthyroidism and anxiety is here today due to complains of recent unintentional weight loss. Patient stated he has lost about 8lbs in the past 2 months, feels tired and fatigued, and also reports occasional dipoplia. Patient also states he likes to self-medicate with marijuana and does not like to use medications. On exam, pt is slightly distressed and worried. Thyromegaly was noted on palpation and his visual acuity in his left eye is 20/40. Patient is also not compliant with his medications (Methimazole and Fluoxetine).
Differential Diagnosis:
1) Most likely hyperthyroidism (Graves’ Disease): Patient has a past medical history of hyperthyroidism and is not compliant with his methimazole which points to his recent weight loss to be an issue of hyperthyroidism. Furthermore, patient also reports vision changes such as dipoplia which further points to Graves’ Disease. Upon physical exam, thyromegaly was also felt, indicating this to be a thyroid issue.
2) Toxic Adenoma: Its important to also have toxic adenoma in our DDX as it also causes hyperthyroidism and produces almost the same symptoms as Graves’ Disease (anxiety, weight loss, weakness, vision changes and palpable thyromegaly).
3) Anxiety: Patient has a past history of anxiety and again, is not compliant with his medications. Excessive worrying can lead to fatigue and feeling tired even if pt got enough sleep. Although not likely, anxiety can lead to weight loss. Anxiety can also be due to hyperthyroidism.
Plan:
1) Order CBC, CMP, TSH, T4/T3, Thyroid-stimulating immunoglobulins (most specific for Graves’ disease).
2) Also order a thyroid ultrasound to check for nodules or masses.
3) Consult patient on the benefits of medicine and medication and how medication works.
4) Consult patient on self-medication and the usage of marijuana.
5) Refer patient to see a psychologist for his anxiety.
6) Continue Methimazole 15 mg orally per day for hyperthyroidism.
7) Continue Fluoxetine 10 mg orally once a day in the morning for anxiety.
8) Refer patient to an ophthalmologist for dipoplia and visual acuity of the left eye 20/40.
This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.
