Answer:
Demographic Data
Patient Name: Mrs. John
Age: 53
Gender at Birth: Female
Gender Identity: Female
Subjective
Chief Complaint- Gain in weight, disturbed sleep, muscle weakness and fatigue.
History of Present Illness (HPI)-The patient has seen a decrease in energy level along with a gain in weight. The patient has not been able to sleep properly for the last 3 months Her fatigue is aggravated with exercise and running. These symptoms have started appearing four to six months ago. The patient does not feel any energy in doing work in the morning.
Past Medical History (PMH): The patient was hospitalized once for delivering her child and once had surgery for appendicitis. However, she does not have a past medical history. The patient is allergic to nuts. The patient has been immunized to date and takes multivitamin tablets on a daily basis.
Family History: The spouse of the patient is healthy. The patient has one child who is also healthy. The mother of the patient suffers from hyperuricemia, the father suffers from hyperlipidemia. The maternal grand mother of the patient suffered from hypothyroidism while the maternal grandfather was physically fit and devoid of any disease. The paternal grandfather and grandmother of the patient were normal and healthy.
Social History: The patient tries to consume a well-balanced diet but fails to do so as the protein consumed is not enough. She avoids too many carbohydrates and sweets in her diet. However, occasionally she does consume pastries and soft drinks. The patient is not much active physically and forces herself to go to the gym for maintaining a daily life style. The patient. Her child is 15 years old and is a female The family of the patient moved 3 years back from Ontario for job requirements and lives in an apartment there. The patient is a social person and has a habit of drinking occasionally and that also a glass of wine. The patient smokes regularly but denies usage of any kind of drugs. The patient has a regular menstrual cycle.
Review of Systems (ROS) as appropriate:
The patient is fat in comparison to her height
She has a swollen face
There are dark circles below her eyes which indicate that she has a disturbed sleep pattern (Barone et al., 2019)
Her pupils her dilated
My tongue is a bit yellowish
The teeth are clean and white
She has a well-balanced gait and walks normally without any support.
Objective
Vital signs
The temperature recorded- 37.9 degrees Celsius
Heart rate- 75 per minute
Blood pressure- 118/76 mmHg
RR- 23 per minute
SPO2 – 98% on RA
Height- 153 cm
Weight- 68 kgs
BMI- 30.2
Physical Examination
General appearance: The patient was awake, alert and in normal orientation. No acute distress is noted. The appearance was noted at the age of 45 and the patient was appropriately dressed with normal balance and gait.
Cardiovascular: Normal in appearance. There were no thrills and lifts
Respiratory: Lungs were distressed due to smoking
Heart rate: It was normal with no such murmurs. Systolic and diastolic sounds were noted.
Swelling: Slight pits in hand and feet were noted. Mild tenderness.
Gastrointestinal: Severe constipation
Genitourinary: Urine flow is normal and is slightly yellowish in colour. No dysuria was observed.
Reproductive: Menstrual flow is regular. Lasts for 5 days, with a heavy flow on the 1st and 2nd days.
Skin: Normal temperature when touched. Skin is coarse and dry. The growth of hair in the body is normal. The skin is dry.
Psychiatric: The patient has no such mental distress and remains in a normal mood, there is no suicidal thought.
Assessment
The patient was presented in the clinic with fatigue and loss of sleep. The respiratory rate was found to be 23 per minute the blood pressure was noted to be 118/76 mmHg. Physical assessment revealed that the patient has severe constipation which was probably due to a lack of consumption of water (Lado, 2019). There was mild tenderness in the hands and feet of the patient due to probable accumulation of body fluids. Lung was distressed due to smoking regularly (Bradbury et al., 2018). Muscle weakness revealed that the patient was somewhat lacking oxygen.
It can be finally diagnosed and concluded that the patient is suffering from oedema which is the result of her absurd weight gain. This is supposed to have resulted from increased movement of body fluids to interstitial spaces from the intravascular spaces. It occurs under capillary hydrostatic pressure which is increased (Sanghvi, 2020). This can probably be due to a lack of protein in the body.
Plan
Chest X-ray
Kidney function test
T3, T4 and TSH test to check for hypothyroidism
Lung function tests
Diuretics for edema- Furosemide; Laxative for constipation- Dulcolax
Rendering patient education regarding the reduction of smoking
The patient should be made to drink an ample amount of water daily (3 litres daily). This may help with constipation (Dupont et al., 2019).
Consume a well-balanced diet; high protein intake and high fibre diet in consultation with a dietician (Bellini et al., 2021).
Follow-up for evaluation on the basis of diagnostic tests done.
Referral
Dietician
Endocrinologist (if thyroid detected)
Gastro-enterologist for constipation
Reference List
Barone, C. R., Boza, J. C., Machado, P. G., & Cestari, T. F. (2019). Association between clinical characteristics, quality of life, and sleep quality in patients with periorbital hyperchromia. Journal of Cosmetic Dermatology, 18(1), 230-235. https://onlinelibrary.wiley.com/doi/abs/10.1111/jocd.12549
Bellini, M., Tonarelli, S., Barracca, F., Rettura, F., Pancetti, A., Ceccarelli, L., … & Rossi, A. (2021). Chronic Constipation: Is a Nutritional Approach Reasonable?. Nutrients, 13(10), 3386. https://www.mdpi.com/2072-6643/13/10/3386/pdf
Bradbury, P., Traini, D., Ammit, A. J., Young, P. M., & Ong, H. X. (2018). Repurposing of statins via inhalation to treat lung inflammatory conditions. Advanced Drug Delivery Reviews, 133, 93-106. https://opus.lib.uts.edu.au/bitstream/10453/128757/3/MED%2029890243.pdf
Dupont, C., Constant, F., Imbert, A., Hébert, G., Zourabichvili, O., & Kapel, N. (2019). Time to treatment response of a magnesium-and sulphate-rich natural mineral water in functional constipation. Nutrition, 65, 167-172. https://www.sciencedirect.com/science/article/pii/S0899900718304969
Lado, W. O. (2019, December). The Effectiveness of Warm Water Therapy for Constipation. In Abstract Proceedings International Scholars Conference (Vol. 7, No. 1, pp. 475-482). https://doi.org/10.35974/isc.v7i1.1088
Sanghvi, D. A. (2020). Periphyseal edema: always pathology or sometimes physiology?. Japanese Journal of Radiology, 38(10), 1004-1005. https://search.proquest.com/openview/9e8cbf03fe000bff999f2daf911c46a8/1?pq-origsite=gscholar&cbl=54542