PATIENT CASE Patient's Chief Complaints "I've been having some bleeding between periods and some rather heavy bleeding w

[answerhappygod]

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 1 (99.11 KiB) Viewed 148 times

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 2 (84.47 KiB) Viewed 148 times

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 3 (57.8 KiB) Viewed 148 times

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 4 (45.53 KiB) Viewed 148 times

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 5 (58.93 KiB) Viewed 148 times

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 6 (64.78 KiB) Viewed 148 times

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 7 (65.89 KiB) Viewed 148 times

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 8 (65.26 KiB) Viewed 148 times

Patient Case Patient S Chief Complaints I Ve Been Having Some Bleeding Between Periods And Some Rather Heavy Bleeding W 9 (94.84 KiB) Viewed 148 times

PATIENT CASE Patient's Chief Complaints "I've been having some bleeding between periods and some rather heavy bleeding with mild cramping during my last two periods. I've also been extremely weak and tired lately, and I've been going to the bathroom more often lately." HPI J.D. is a 37 yo white woman who presents to her gynecologist complaining of a 2-month his- tory of intermenstrual bleeding, menorrhagia, increased urinary frequency, mild inconti- nence, extreme fatigue, and weakness. Her menstrual period occurs every 28 days and lately there have been 6 days of heavy flow and cramping. She denies abdominal distension, back- ache, and constipation. She has not had her usual energy levels since before her last pregnancy. PMH Upon reviewing her past medical history, the gynecologist notes that her patient is a GPS with four pregnancies within four years, the last infant having been delivered vaginally four months ago. All five pregnancies were unremarkable and without delivery complications. All infants were born healthy. Patient history also reveals a 3-year history of osteoarthritis in the left knee, probably the result of sustaining significant trauma to her knee in an MVA when she was 9 yo. When asked what OTC medications she is currently taking for her pain and for how long she has been taking them, she reveals that she started taking ibuprofen, three tablets each day, about 2% years ago for her left knee. Due to a slowly progressive increase in pain and a loss of adequate relief with three tablets, she doubled the daily dose of ibuprofen. Upon the recom- mendation from her nurse practitioner and because long-term ibuprofen use can cause pep- tic ulcers, she began taking OTC omeprazole on a regular basis to prevent gastrointestinal bleeding. Patient history also reveals a 3-year history of HTN for which she is now being treated with a diuretic and a centrally acting antihypertensive drug. She has had no previous surgeries.
SES OF THE BLOOD FH • Father alive, age 66, with angina • Mother alive, age 62, with arthritis • One brother, age 35, alive with DM and hyperlipidemia • One sister, age 34, with history of depression and hypothyroid disease • Both paternal grandparents had heart disease • Five children, ages 4 months to 9 years, alive and well SH • Born in the United States of Greek parents • Married homemaker, lives with husband • Non-smoker and non-drinker • (-) illicit drug use • Strict vegetarian X 5 years Admits to lacking a regularly scheduled exercise program, "although the kids keep me run- ning all the time" - ROS I • Reveals a craving for cold celery for the past 3 weeks (+) mild urinary urgency with incontinence • (-) hematuria, hematemesis, hemoptysis, melena (+) recent mild SOB with exertion, progressive irritability with difficulty concentrating • (-) palpitations . () abnormal nail bed changes, sore tongue and lips, headaches, restless legs, chest pain, cold intolerance, dysphagia, cold hands and feet, dizziness, lightheadedness • (-) history of cardiac or pulmonary disease
Meds • 35 ug ethinyl estradiol with 0.5 mg norethindrone (10 tablets) and 35 «g ethinyl estradiol with 1.0 mg norethindrone (11 tablets) monthly • OTC ibuprofen 200 mg po 6X/day PRN • OTC omeprazole 20 mg po QD Hydrochlorothiazide 30 mg and methyldopa 500 mg po BID (-) for multivitamins, calcium supplements, and iron supplements . . All • Erythromycin upset stomach Aspirin upset stomach - PE and Lab Tests Gen • Tired- and pale-looking, overweight white female in NAD • Appears her stated age • Pleasant, cooperative, alert, and oriented X 3 VS I See Patient Case Table 88.1
CASE STUDY 88 IRON DEFICIENCY ANEMIA 423 Patient Case Table 88.1 Vital Signs BP 100/40 sitting, right arm RR 140 and regular T 17 and unlabored 98,0°F HT WT P 173 lbs Skin • Pale and cool with normal turgor (-) rash Seborrheic keratosis over upper back . HEENT • NC/AT • PERRLA • EOMI • Normal funduscopic exam • Bluish sclerac Slightly pale conjunctiva • Ear canals clear and eardrums negative I • Nares normal • (-) swelling or tenderness above maxillary and ethmoid sinuses • Teeth intact Tongue mid-line and negative for glossitis • Tonsils intact and normal • Oral mucous membranes pale but moist Pharynx unremarkable (-) angular stomatitis .
Neck/LN • Normal motion of neck • Trachea mid-line • No lymphadenopathy or thyromegaly • No bruits, masses, or other abnormalities Lungs/Thorax • Bilateral breath sounds • No wheezes or crackles • (-) CVAT Breasts • Symmetric bilaterally • Without masses, discoloration, dimpling, or discharge • Normal axilla Cardiac • Tachycardia • Systolic murmur heard best at right sternal border • (-) rubs
Abd . Slightly obese, soft, and tender to palpation • No masses (+) bowel sounds • (-) hepatomegaly and splenomegaly . Genit/Rect • Good anal sphincter tone • Guaiac-negative stool • Normal external female genitalia Irregular, non-tender nodularity of uterus on bimanual examination MS/Ext • Joint enlargement and limited ROM of left knee, consistent with DJD • (-) paresthesias, clubbing, or cyanosis • Pulses 2+ bilaterally • No edema or ulcers Neuro . • A & O X 3 • Good auditory acuity Proprioception intact bilaterally • Coordination intact • (-) ataxia and nystagmus • CNS II-XII grossly intact • Muscle strength in UE and LE equal bilaterally • Vibratory sense intact • Reflexes intact at 2+ • Mental status intact Plantars downgoing
• Mental status intact • Plantars downgoing Laboratory Blood Test Results See Patient Case Table 88.2 19 pg Patient Case Table 88.2 Laboratory Blood Test Results Na 141 meq/L MCV 71 FL Alb K 4.2 meq/L MCH Cholesterol Cl 99 meq/L MCHC 27 g/dL Ca HCO, 27 meq/L WBC 7.9 X 10mm Iron BUN 20 mg/dL Plt 623 X 10mm TIBC Cr 1.0 mg/dL AST 36 IU/L Transferrin sat Glu, fasting 97 mg/dl. ALT 43 IU/L Ferritin Hb 9.1 g/dL Bilirubin 1.2 mg/dL FEP Het 27.5% LDH 114 IU/L Vitamin B12 RBC 3.3 X 10mm Protein 7.1 g/dL Folic acid 4.4 g/dL 273 mg/dl. 9.1 mg/dL 35 pg/dL 706 g/dL 5.0% 9.7 ng/ml 54 g/dL. 680 pg/mL 420 ng/ml
CASE STUDY 88TRON DEFICIE Urinalysis See Patient Case Table 88.3 (-) Patient Case Table 88.3 Urinalysis Color Yellow Protein Appearance Hazy Glucose pH 6.4 Hemoglobin SG 1.017 Bilirubin (-) (+) (-) Ketones Bacteria RBC WBC © (-) 2/HPF 2/HPF Peripheral Blood Smear • (+) significant number of hypochromic, microcytic RBC (+) mild anisocytosis and poikilocytosis . Pelvic Ultrasonography Irregularly enlarged uterus with 5 distinct uterine masses visible • 3 masses submucous in location (1-1" in diameter) • 1 mass subserous in location (2" in diameter) • 1 mass intramural in location (/" in diameter) Findings are consistent with a diagnosis of uterine fibroids/leiomyomas .
Patient Case Question 1. The patient in this case study has seven potential contributing factors for the development of iron deficiency anemia. What are they? Patient Case Question 2. What is causing increased urinary frequency, urinary urgency, and mild incontinence in this patient? Patient Case Question 3. What is causing intermenstrual bleeding and menorrhagia in this patient? Patient Case Question 4. Why did the gynecologist question the patient about constipation? Patient Case Question 5. Why is this patient taking ethinyl estradiol and norethindrone tablets? Patient Case Question 6. Why were serum vitamin B12 and folic acid concentrations tested? Patient Case Question 7. What is the potential significance that the patient was born of Greek parents? Patient Case Question 8. Symptoms are subjective clinical manifestations of an illness that can only be reported by the patient. Identify seven clinical symptoms in this case study that are consistent with a diagnosis of iron deficiency anemia. Patient Case Question 9. Signs are objective clinical manifestations of an illness that can be observed by someone other than the patient. Identify a minimum of twenty clini- cal signs in this case study that are consistent with a diagnosis of iron deficiency anemia. Patient Case Question 10. Provide five different treatment modalities that will help resolve iron deficiency anemia in this patient. Patient Case Question 11. To which stage of iron deficiency has the patient in this case progressed?