HPI Susan Bean is a 22-year-old Caucasian female that presents today with c/o hair growth on her chest and back. This has started around age 13 with puberty and has progressively gotten worse, she has tried OTC hair removal products, but nothing seems to help.

/in /by

Week 5 Discussion PCOS
COLLAPSE
Patient Information:
S.B, 22 years old, female, Caucasian S.
CC: Increased Hair growth
HPI: Susan Bean is a 22-year-old Caucasian female that presents today with c/o hair growth on her chest and back. This has started around age 13 with puberty and has progressively gotten worse, she has tried OTC hair removal products, but nothing seems to help. She is currently on medications Zoloft for depression and metformin for her DM2.
Current Medications: Metformin BID before meals 500mg oral
Zoloft 50mg once daily oral
Allergies: NKA
PMHx:
immiunizations up do date Soc & Substance Hx: Susan works as a receptionist at an insurance company. She stated she sits frequently and has slowly gained weight because of this and attributed her DM2 to her weight gait. The weight gain has caused some insecurities and depression. She is supported by her mom and sister, her dad left when she was young. She is also currently in a relationship and on birth control to prevent pregnancy. She denies history of IPV or any abuse. She doesn’t not smoke, she occasional drinks socially, and no other substance use.
Fam Hx: Mom obesity, miscarriages, diabetes
Dad Unknown History
Sister No history Maternal Grandma
Maternal Grandpa Paternal Grandma Unknown history Paternal Grandpa Unknown history Surgical Hx: No surgical history Mental Hx: Depression
Violence Hx: None
Reproductive Hx: Menstrual history LMP: 3/8/2021 regular and moderate flow, pregnant: No, she experienced a miscarriage about a year ago when she was just using condoms and decided to go on COC, Contraceptive use: COC started after mis carriage and when she was experiencing irregular menstrual cycles and she uses condoms. Types of intercourse: vaginal. No other concerns. ROS: General: Weight gain, no fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
Skin: Mild acne of face. No rash or itching.
CV: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
Lung: No shortness of breath, cough, or sputum.
GI: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GU: Burning on urination. Neuro: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MSK: No muscle pain, back pain, joint pain, or stiffness.
Hematologic: No anemia, bleeding, or bruising.
Lymphatic: No enlarged nodes. No history of splenectomy.
Psych: present history of depression
Endo: Reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
O.
Physical exam: Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 136/74, height 5’6” and weight 235 lbs. (which was up from last year). BMI 38, waist circumference 92 cm HEENT: mild acne on face Lung: clear to auscultation, irregular patchy hair distribution on back. CV: regular sinus rhythms without murmur or gallop Abd: soft, non-tender, liver normal, Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings. Irregular patchy hair distribution on chest VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted Cervix: friable, some petechia no cervical motion tenderness. Uterus: mid mobile, non-tender Adnexa: without masses or tenderness Perineum: wnl Rectum: wnl Extremities: full rom, skin clear, no edema, reflexes 1+. Neurological: CN II-12 grossly intact.
Diagnostic results: TSH due to weight gain
fasting lipid profile due to BMI risk factors 2-hour glucose tolerance test
Progesterone level due to hirsutism Free testosterone level A.
Differential Diagnoses 1. PCOS is an hyperandrogenic disorder that can present with a variety of symptoms making it harder to diagnose. PCOS presentation can include hyperandrogenism (hirsutism, acne, and androgenic alopecia), menstrual irregularity or subfertility/infertility (Schuiling & Likis, 2017). If history, PE, and laboratory testing rule out all other possible causes, then a PCOS diagnosis is likely, there is no single diagnostic criteria. PCOS is associated with classic ovarian morphology that can be seen in a pelvic ultrasonography (Schuiling & Likis, 2017). Half the people with PCOS are also obese, approximately 50%-70%have insulin resistance, 70% have at least one lipid level that is borderline or high, 1/3 to ½ have metabolic syndrome, and rates of depression, anxiety, or binge eating are higher (Schuiling & Likis, 2017). This puts PCOS patients at increased risk for adverse health outcomes such as endometrial cancer, DM2, and cardiovascular disease. PCOS is also one of the most common causes of female infertility, affecting 6% to 12% (as many as 5 million) of US women of reproductive age (CDC, 2020).
2. Thyroid Disorders such as hypothyroidism elevated TSH level and can cause symptoms of fatigue, increased insensitivity to heat and cold, weight gain, hoarseness, puffiness of the face and hands, heavy or irregular menstrual periods, dry skin, dry and brittle hair, and depression (Buttaro, et al, 2017). Hypothyroidism can be managed with oral levothyroxine daily. 3. Nonclassical adrenal hyperplasia is rare and occurs in approximately 2% of women with androgen excess (Schuiling & Likis, 2017). This condition can be clinically indistinguishable from PCOS (Schuiling & Likis, 2017).
P. -Discussion on lifestyle modifications such as healthy diet, weight management, and regular exercise to control the symptoms of PCOS. Weight loss alone will decrease androgen levels, decrease hirsutism, resumption of ovulation, improve menstrual function, reduce miscarriage rate, and improve fasting insulin tolerance, and lipid levels (Schuiling & Likis, 2017). -Antiandrogens are effective medications in treatment of hirsutism and can be used in combination with COC. Mechanical hair removal can be used such as shaving, plucking, waxing, or using creams such as Eflornithine HCl 13/9%, these options do not stimulate further hair growth (Schuiling & Likis, 2017). Electrolysis and laser therapy are other options that can be more expensive but are permanent. -Continue Metformin for insulin resistance, metformin has shown to increase ovulatory frequency and decrease androgen levels (Schuiling & Likis, 2017). Metformin also decreases fasting insulin levels, blood pressure and LDL cholesterol levels (Schuiling & Likis, 2017). Reflection
I decided to do my case study on PCOS because I have not actually seen this diagnosed yet in my clinical rotation. I had a recent coworker recently struggling with infertility, so this sparked my interest, as she is does seem to have some of the symptoms and r/f. It would be interesting to know what test she had done and if PCOS is a possibility for her. I feel it could be underdiagnosed because of the complicated history, PE, and diagnostic tests needed for diagnosis. I learned a lot about PCOS while doing research for this case study that I will be able to use during my clinical rotation and my own practice in the future. References
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.
Center for Disease Control and Prevention (CDC, 2020). PCOS (Polycystic Ovary Syndrome) and Diabetes. Retrieved from. https://www.cdc.gov/diabetes/basics/pcos.html Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Jones and Bartlett Publishers.