Introduction
The object of this week’s study is a 21-year-old woman. At present she complaints about frequent headaches and general bad condition. Besides, she is bothered by gaining some weight in the last month. The lady supposes she has a thyroid problem because it was observed in her family. She lacks energy for her usual activities and reports feeling anxious when leaving a house. The examination shows that her organism is functioning within normal limits. The woman looks troubled.
I suppose that the woman may experience depression. She may be exhausted at work and does not have enough rest which results in headaches and overall weakness. Still, the laboratory tests and screening will give more information on the disorder in her organism.
Important Subjective and Objective Data
I think that the subjective data useful for proper diagnosing of this patient is the information on her occupation, family situation, and daily activities. They will help to evaluate her psychological condition. The objective data will be received from further screenings and will include the test on thyroid-stimulating hormone first of all. Another useful test will be that for non-protein-bound thyroxine. They are the tests that are informative about the thyroid problem and the most reliable in this case.
Patient Management and Treatment
After obtaining tests’ results I would refer the patient to endocrinologist and geneticist to prove the absence or presence of thyroid problem and its genetic character. Besides, I would refer her to a psychologist to evaluate the emotional condition. Patient management will include the following steps. First of all, I would be emphatic at the examination. I would not make any diagnosis until the tests are ready and the other connected specialists give their opinions. I would suggest the pills to deal with headaches after the careful considerations of the possible side effects. After the cause of the symptoms is defined, the appropriate treatment will be prescribed.
Follow-up and Further Considerations
I suppose that apart from traditional treatment some complementary therapies can be useful. Considering the patient’s weakness and general bad condition, I suggest trying acupuncture and aromatherapy. They will help to relax and distract attention from the issues not connected with health (Kelner, 2014). Besides, to meet the woman’s worries about gaining weight I would advise yoga classes.
Depending on the final diagnosis, I would suggest the patient’s return for follow-up in two weeks or a month. The repetition of blood test and other investigations are necessary to check the efficiency of the prescribed therapy. However, in case the patient feels worse, she can visit me any time.
To my mind, the patient’s education is crucial in this case. It is aimed at informing a person on the peculiarities of the illness and self-care (Bastabke, 2016). The lady tried making a diagnosis for herself based on the knowledge about the illness history of her family. She should be aware that such an approach can make her condition worse. I would suggest her the information on her illness after the diagnosis is proved.
I would bill the patient for the first visit. I would use the level III of evaluation and management (American College of Emergency Physicians, 2011).
Conclusions
In general, the problems reported by a young woman is wide-spread. Young people are busy at studies or work and do not pay much attention to primary symptoms unless they influence the quality of life. Thus, health promotion is necessary to attract the attention of society to health issues.
References
American College of Emergency Physicians. (2011). ED facility level coding guidelines. Web.
Bastabke, S.B. (2016). Essentials of patient education (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
Kelner, M. (2014). Complementary and alternative medicine: Challenge and change. New York, NY: Routledge.