Mary T. is a 29 year old referred to you because of a routine screening test, which revealed markedly elevated cholesterol. ROS identified dry skin, 10 lb. Weight gain, regular but heavy menses, easy and frequent bruising, milky breast discharge and fatigue. Meds include multivitamin and oral contraceptives.
- What laboratory tests would you order for her?Mary further explains that she has had a stressful year. Her mother, whom she had cared for during the terminal phases of breast cancer died. She took several months off from work due to depression following her mother’s death. She now works full-time as a travel agent and discusses having difficulty concentrating. She works out of her home and cares for her 4-year-old daughter.
- Discuss the normal grieving process in view of her symptoms?PE: BP 120/72, Weight 145, pounds Height 61 inchesSkin: dry, scaly, slight loss of scalp hair, several bruises on arms and legs, diminished DTRs, thyroid slightly enlarged.Labs: glucose and electrolytes WNL, Total Cholesterol 267/LDL 178/HDL 40/Triglycerides 167, HGB 11, HCT 33.4, TSH 20.
- List 5 differential diagnoses based on the available data.
- How would you explain your findings to her? What will you tell her about her labs?
- What follow-up labs will you order and when?
- How do you plan to treat her cholesterol? Her fatigue?
Expert Solution Preview
Introduction:
In this scenario, a 29-year-old patient, Mary T., has been referred to us due to markedly high cholesterol levels discovered during a routine screening. The patient has also reported several other symptoms, including dry skin, weight gain, heavy menses, frequent bruising, milky breast discharge, and fatigue. As a medical professor in charge of creating assignments and evaluations for medical college students, I will provide answers to the following questions related to Mary’s case.
1. What laboratory tests would you order for her?
In Mary’s case, elevated cholesterol levels have already been identified through routine screening. Therefore, I would recommend ordering further lipid panel tests to assess different types of lipids such as total cholesterol, triglycerides, HDL, LDL, and VLDL. Additionally, thyroid function tests, such as TSH, should be performed due to the patient’s thyroid’s slightly enlarged size. A complete blood count (CBC) could identify any anemia that may be contributing to symptoms such as fatigue and bruising. Further, a liver function test may help to exclude any associated hepatic cause suggesting hyperlipidemia.
2. Discuss the normal grieving process in view of her symptoms?
Grieving is a normal process that individuals go through after losing someone close to them. Generally, the process involves accepting the reality of the loss, experiencing the pain of the loss, adjusting to the life without the deceased, and finding a way to maintain ties with the deceased while embracing life. In Mary’s case, her symptoms may be indicative of a complicated mourning process. The loss of her mother, her primary caregiver, and the depression she experienced following the loss can significantly affect her mental health and cause physical symptoms. An appropriate screening test for depression, like the Patient Health Questionnaire (PHQ-9), may help identify signs of depression, and psychological counseling or stress reduction training may be prescribed.
3. List 5 differential diagnoses based on the available data.
Based on the available data, the following five differential diagnoses may be considered:
1. Hypothyroidism
2. Iron-deficiency anemia
3. Cushing’s syndrome
4. Pituitary tumor or adenoma
5. Hyperprolactinemia.
4. How would you explain your findings to her? What will you tell her about her labs?
Given Mary’s symptoms and lab results, she could have a problem with her thyroid gland, leading to hypothyroidism. Her anemia, together with easy and frequent bruising, may account for the decreased number of platelets due to various conditions, including thrombocytopenic purpura or leukaemia. I would tell her that her cholesterol is high, and changes in diet and lifestyle choices are essential to manage it effectively. Additionally, I would advise her of the possibility of a hormonal imbalance being the underlying cause of the symptoms she is experiencing. I would suggest scheduling a follow-up visit with me to discuss these findings and further evaluation and diagnosis.
5. What follow-up labs will you order and when?
I will order a more comprehensive lipid panel, which measures blood fats’ different types, after 3-6 months to monitor Mary’s response to lifestyle modifications and medication prescribed. Additionally, a CBC for any diagnostically significant changes in RBC, WBCs, and platelets, ferritin, iron level for evaluation of iron deficiency anaemia, and liver function tests for monitoring hepatic enzymes is recommended periodically basis.
6. How do you plan to treat her cholesterol? Her fatigue?
The first line of defense against high cholesterol levels is making lifestyle changes, including weight management through regular exercise and a balanced diet low in cholesterol and trans fats. A dietary chart and regular nutritionist counseling would be beneficial in identifying and promoting a healthy diet. If Mary’s cholesterol levels do not improve, medication may be prescribed like statins. For fatigue associated with iron-deficiency anemia, iron-rich foods, iron supplementation together with Vitamin C supplementation to absorb dietary iron can help treat fatigue. In case of hypothyroidism, thyroxine supplementation may be prescribed on further diagnosis. Further, relaxation techniques, regular meditation, progressive muscle relaxation, and aerobic exercises may help manage fatigue associated with depression.
Conclusion:
In conclusion, Mary’s case highlights the importance of thorough assessment and evaluation of a patient’s medical history, symptoms, and laboratory results to formulate a proper diagnosis, followed by patient education, lifestyle modifications, and medications as required.
