Response to Nkendelim

Please respond to this case study.You can agree on the differential diagnoses, make suggestion on additional treatment or diagnostic test.

 

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Week 5 Case Study

SC is a 22years old Caucasian female who presents to the clinic with complaints of thick, unwanted facial, chin and chest hair. She first noticed the coarse facial hair at age 15 and have since resolved to shaving frequently to remove hair. She reports that her maternal aunt also has the same problem. SC is a nulliparous woman, a unit clerk at her community hospital. She denies smoking or alcohol use. She denies any medical history, prescription medication and no known drug allergies. Gyn history include menarche at age 13, menstrual cycle is irregular, and flows for 3days. Occasionally takes OTC Tylenol 500mg for menstrual cramps. SC has gained 10lbs in one year and reports that the facial hair makes her feel insecure and uncomfortable.

 

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Differential Diagnosis:

Hirsutism, Polycystic Ovary Syndrome and Congenital Adrenal Hyperplasia

 

Hirsutism (First Priority): This condition is excessive hair growth in certain areas of a woman’s body that is generally thought to be a male’s pattern of hair growth. Coarse hair growth in areas such as the upper lip, chin, chest, sideburn area, back, lower abdomen and inner thigh in a woman is thought to be caused by excessive production of androgen- mostly testosterone (Harvard Health Publication, 2020). Women normally have low level of androgen, but when hair follicles are overstimulated by excess androgen production, unwanted hair growth and virilization results. For most women this causes body image issues, depression and social isolation. According to Matheson and Bain (2019), Hirsutism has been reported in 5% to 15% of women and is often associated with decreased quality of life and significant psychological stress. Risk factor for hirsutism include familial tendency, obesity (due to increased androgen production) and long-term use of certain medications like minoxidil and Dilantin.

            The degree of Hirsutism can be evaluated using the Ferriman-Gallwey score for hirsutism.  Eleven androgen body areas (recently modified from 9 to 11 in 2001) are assessed and given a score of 1-4. A total score of less than 8 is considered normal, a score of 8 to 15 indicates mild hirsutism; and a score greater than 15 indicates moderate to severe hirsutism (Matheson and Bain, 2019). While hirsutism diagnosis might be idiopathic, often originating from a familial trend, 85% of cases originate from Polycystic Ovary Syndrome, Non-classic Congenital Adrenal Hyperplasia, Cushing syndrome, Thyroid disorders, and androgen secreting tumors. When patients present with symptoms of gynecologic conditions, it is important to meticulously analyze their symptoms because they may represent a cascade of other health problems.

Polycystic Ovary Syndrome (PCOS): Is a common endocrine disorder, which affects 4%-6% of reproductive-aged women (Towner and Linder, 2019). PCOS have been associated with chronic anovulation, hyperandrogenism, obesity, acne, alopecia, insulin resistance, infertility, acanthosis nigricans and is the most common cause of hirsutism (Matheson and Bain, 2019).  

SC presents with unwanted facial chin, and chest hair, as well as menstrual irregularity with weight gain of 10lbs in one year. These subjective data need to be explored in depth to attain the root cause of SC’s health problems. More information regarding the onset and previous treatments of hirsutism should be obtained, as well as her family, medical, medication, and gynecologic history, to help make appropriate diagnosis.

Tests: Laboratory studies in hirsutism serve both to confirm the clinical impression of hyperandrogenism and to identify other sources of excess androgens, either adrenal or ovarian (Griffing, 2020).

  • Serum Testosterone
  • Serum DHEA- sulfate test (Dehydroepiandrosterone sulfate-DHEA is androgen hormone produced by the adrenal glands)
  • Serum FSH
  • Diabetes screening: Women with hirsutism, PCOS, obesity, or acanthosis nigricans may have insulin resistance, therefore screening for diabetes is required (Griffing, 2020).
  • Pelvic exam and sonogram to rule out androgen secreting tumors

Treatment:

  • Plucking, waxing and shaving excess hair are self-care methods which are temporary
  • The combined oral contraceptives have been used as initial therapy for women with hirsutism caused by androgen production.
  • Anti-androgen agents such as spironolactone, Finasteride and Avodart can be used to remove hair due to their androgen suppression effects. But it is worth mentioning that these agents are teratogenic and should be avoided in pregnancy.
  • Other procedures that can be suggested to patient are laser therapy or electrolysis

These treatment modalities have their pros and cons, the patient and their practitioners should discuss which is appropriate based on the severity of hirsutism or the degree of patient’s psychological stress.

 

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