Question

Sarah, a 50-year-old G2P1011 woman, presents to the office with increasing hot flashes, night sweats, vaginal dryness, and insomnia over the past 4 months. She indicates that she has made some dietary changes, specifically decreasing the intake of spicy foods and hot tea; however, they seem to have little effect on her symptoms. Her last menstrual period (LMP) was 14 months ago. She is also experiencing some constipation, dry skin, and thinning hair. Her mother experienced menopause at about age 51 years and seemed to “sail right through it.” Overall, Sarah’s general health has been good. Her BMI is 26 and vitals are within normal limits. She had a normal pelvic at her well-woman visit 10 months ago. Her uterus, ovaries, and cervix are intact. She exercises by walking for 30 minutes a day about 4 to 5 days a week. She takes a multivitamin every day.

1. Discuss your three differential diagnoses for Sarah and include your reasoning for each. What is the most likely diagnosis?

3. What further testing is recommended for Sarah and why?
4. Discuss the medication you would prescribe for Sarah. Is there any further information you should obtain from Sarah before prescribing medication?
5. Discuss your recommendations for a follow-up.
6. What educational information is important to provide to Sarah?

Answer 1

ANSWER:

The three differential diagnosis for sarah are

disease/ condition	differentiate sign and symptoms	differentiating test
hyperthyrodism	menstrual irregularity , hot flushes, tachycardia, tremor, hair loss, anorexia, weight loss	Thyroid stimulating hormone (TSH) level may be suppressed
hypothyrodism	heavy bleeding, amenorrhea, fatigue, hair loss, dry skin, constipation and weight gain	TSH level may be elevated
anorexia	amenorrhea, vaginal dryness and sleep disturbance	FSH levels will be low. Ovarian reserve tests are likely to be normal.
Menopause	iregular period, hot flush, night sweeting , vaginal dryness, thining and dry skin, mood changes

The most likely to be diagnose as hypothyroidism only.

Further Thyroid function test should be check properly to provide accurate dose of medication.

MEDICATION

Tab. thyroxine: it a hormone replacement therapy provided to decrease TSH level in the blood.

Information to be given to patient

- The Thyroxine tablet should be taken before breakfast in early morning or in empty stomach.

FOLLOW UP RECOMMENDATION

• repeat blood test every 6 to 10 weeks and should show to doctor
• excercise can be done

EDUCATION TO SARAH

• Education to sarh should include regarding disease condition, sign and symptom
• advice to do exercise properly
• the medication should be taken only in morning
• advice not to miss even one dose od medication
• follow up should be done on time