K.P. a 48-year-old woman presents to your primary care office with a 6-week history of fatigue, concentration difficulties, appetite changes, constipation, and weight gain. She reports feeling sleepy all the time and somewhat “down in the dumps.” She is a substitute teacher at the local public school and has had difficulty enjoying a job she has always “loved.” She decided to come in today because “something is wrong with me.” During this period, she has had irregular menstrual periods.
Findings from her physical exam reveal dry skin, thinning hair; brittle nails, sluggish gait, and slow response to questions. She has gained 20 lbs. since her last annual exam (last year 135 lbs. and today she weighs 155 lbs.). Although she answers questions slowly, she is alert and oriented, goal-directed, and her speech is clear. Her effect is blunted. She denies a history of psychiatric treatment and suicidal ideations.
1-With the above information, construct the subjective and objective data in a SOAP Note format.
2-Is there any other information that you would obtain to assist you in determining treatment options?
3-Discuss the top three differential diagnoses.
4-What initial diagnostics would you order?