ASSESSMENT 7 HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 43 YO F C/OWEIGHT GAIN OF 15 LBS IN 2 MONTHS. COLD INTOLERANCE, DRY SKIN AND HAIR LOSS. NO CONSTIPATION, NO VOICE CHANGES, APPETITE IS GOOD. DENIES FATIGUE, DEPRESSION, FEVER, CHILLS OR CHEST PAIN. LMP 2 WEEKS AGO, IRREGULAR. PREVIOUS NORMAL MENSES EVERY 4 WEEKS 3-4 PADS A DAY, CURRENTLY MENSES EVERY 6-7 WEEKS AND 2 PADS PER DAY. THIS ALTERATION BEGAN 4 MONTHS AGO. MENARCHE AGE 14, TWO PREGNANCIES TWO CHILDREN, UNCOMPLICATED VAGINAL DELIVERY. DOES NOT USE CONTRACEPTIVES. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: NONE MEDICATIONS: LITHIUM PMH: DIAGNOSED WITH BIPOLAR 5 MONTHS AGO, CONTROLLED WITH LITHIUM PSH: NONE FH: BROTHER AND FATHER ARE OBESE, MOTHER IS ALIVE AND HEALTHY SH: SMOKED 1 PPD FOR 10 YEARS, QUIT SMOKING 6 MONTHS AGO, NO ETOH, NO DRUG USE, WORKS AS A LIBRARIAN, LIVES WITH HUSBAND AND CHILDREN. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. THE PATIENTS HEAD APPEARS NORMOCEPHALIC AND ATRAUMATIC. HER THYROID APPEARS WITHIN NORMAL LIMITS AND NO LYMPHADENOPATHY. HER ABDOMEN IS SOFT AND NONTENDER WITH POSITIVE BOWEL SOUNDS HEARD. NO GUARDING WAS PRESENT. THERE IS NO BRUISING, DRY SKIN, EDEMA OR CYANOSIS PRESENT. HER REFLEXES ARE INTACT AND SYMMETRICAL. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.

Diagnosis #1: WEIGHT GAIN DUE TO SMOKING CESSATION HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -WEIGHT GAIN -THYROID WNL -STOPPED SMOKING SINCE 6 MONTHS -ABDOMEN SOFT -ON LITHIUM SINCE 5 MONTHS Diagnosis #2: HYPOTHYROID HISTORY FINDING(S) -WEIGHT GAIN -COLD INTOLERANCE -DRY SKIN AND HAIR LOSS Diagnosis #3: LITHIUM RELATED OBESITY HISTORY FINDING(S) -ON LITHIUM SINCE 5 MONTHS -WEIGHT GAIN -COLD INTOLERANCE Diagnostic studies: -TSH -URINE HCG -GLUCOSE -24 HOUR FREE CORTISOL -DEXAMETHASONE SUPRESSION TEST

PHYSICAL EXAM FINDING(S) -THYROID WNL -ABDOMEN SOFT

PHYSICAL EXAM FINDING(S) -THYROID WNL -ABDOMEN SOFT