H&P2
Daniela Arias Rodriguez
Family Medicine H&P#2 9/23/20
Identifying Data:
Name: Ms. D
Address: Queens, NY
Date of Birth: 20 yrs old
Date & Time: September 23, 2020
Location: Amazing Medical Services
Source of Information: Self
Source of Referral: self
Chief complaint: Irregular periods
HPI: Ms. D is a 20 y/o Indian American female with PMHx of asthma presented to the office with complaints of irregular periods since her menarche. Pt had her menarche at the age of 11. Pt was reassured by her previous PCP that it was normal for her age group and was advised to control her weight. During the office visit, she reports being actively bleeding for a total of 10 days. Pt started spotting on 9/4 until her period came on 9/14. Pt reports that bleeding is becoming lighter. As per patient, her periods usually last 5-12 days with moderate flow and mild pain on the first day. On one occasion, pt reports not getting her period for six months. Pt has never been sexually active. Pt has noticed that weight control helped regulate her periods in the past. She admits weight gain in the past few months due to the pandemic. Pt would like to start OCP to better control her periods. Pt denies dizziness, light-headedness, SOB, fatigue, headache, abnormal vaginal discharge, pain before periods, urinary symptoms, abdominal pain, N/V/D, constipation, chest pain, fever, sore throat, sick contact, recent travel or COVID positive contact.
Past Medical History:
Present illnesses – Asthma
Past medical illnesses – Asthma
Hospitalized – (see PSHx).
Immunizations -up to date
Past Surgical History:
denies
Medications:
Albuterol Sulfate HFA 108 aerosol 1 puff prn every 4 hours
Allergies:
No allergies
Family History:
Father, alive, diabetes mellitus and HTN
Mother, alive, diabetes mellitus, HTN and asthma
Social History:
Ms. D is Indian American female who lives with her parents and is a full-time student. Pt denies smoking, use of alcohol or recreational drugs.
ROS:
Gen – Admits weight gain in past few months (unaware of how much). Denies decrease in appetite, weight loss, fever, chills, fatigue or night sweats.
Skin, hair, nails—Denies hyperpigmentation, acne, dryness, excessive sweating, change in texture or change in hair distribution.
Head— Denies headache, dizziness, vertigo, syncopal episodes or recent head trauma
Eyes—Denies blurring vision, photophobia, pruritus, dryness, diplopia, scotoma, lacrimation, fatigue with use of eyes or use of glasses.
Ears— Denies pain, discharge, hearing difficulty or tinnitus.
Nose/sinuses—Denies nose bleed, discharge or obstruction.
Mouth/throat— Denies sore throat/tongue, bleeding gums, mouth ulcers or changes in voice.
Neck—Denies swelling, lumps, stiffness or decreased range of motion
Pulmonary – Denies dyspnea, cough, orthopnea, dyspnea, hemoptysis or wheezing.
CV— Denies chest pain, HTN, peripheral edema, palpitation, irregular beats, syncope and known heart murmur.
GI— Denies abdominal pain, N/V/D, decreased appetite, dysphagia, hematemesis, jaundice, hemorrhoids, bloody stools or heartburn.
GU—Denies denies hematuria, frequency, nocturia, urgency, oliguria, dysuria, polyuria, hesitancy, incontinence or dribbling.
Menstrual/Obstetrical — Pt admits still having her period since September 14. Menarche at the age of 11. She reports irregular periods since her menarche. Periods are irregular (without period >28 days), moderate in flow and lasting 5-12 days. G0P0000. Denies ever being sexually active. Denies abnormal vaginal discharge, itchiness, lesions or having a pap smear.
Nervous— A&O x3. Denies hx of seizures, headache, loss of consciousness, numbness, tingling, ataxia, loss of strength and change in cognition or memory.
Musculoskeletal—Denies swelling, muscle pain, redness, deformity of muscles/ joints or arthritis.
Peripheral— Denies peripheral edema, coldness, intermittent claudication, varicose veins, and change in color.
Hematological— Denies easy bruising, anemia, hx of blood transfusion, lymph node enlargement or Hx of DVT/PE.
Endocrine—Denies polyuria, diaphoresis, polydipsia, polyphagia, heat or cold intolerance, goiter and hirsutism.
Psychiatric— Patient denies depression or suicidal ideations.
VS: T 98.7 F forehead, HR 90 bpm, BP 108/70 left arm seated, RR 16, SpO2 99% room air, BMI: 29.7
Physical Exam:
Gen – AOx3, without apparent distress, average build and appears younger than her stated age.
Skin: warm & moist, good turgor, non-icteric, no visible lesions, scars or tattoo.
Nails: no signs of clubbing, lesions, paronychia, capillary refill <2 second.
Hair: Evenly distributed with no signs of erythema or dryness in the scalp.
Head: Normocephalic, non-tender to palpation with no signs of swelling or trauma.
Ear: Intact tympanic membrane with undisturbed cone of light bilaterally. No lesions or erythema in the auditory canal bilaterally. Whispering test unremarkable bilaterally.
Eyes: white sclera and pale conjunctiva bilaterally. PERRLA, full visual fields and intact EOM with no nystagmus. Visual acuity 20/20 bilaterally. Unremarkable optic disc, no hemorrhage or exudates bilaterally on fundoscopy.
Mouth: pink and moist mucosa with no masses, thrush or lesions. No signs of tonsil exudate or enlargement. Uvula middle line with no signs of edema or lesion.
Trachea/thyroid: midline and non-tender to palpation. Non-palpable nodule or bruit on auscultation. No lymphadenopathy.
Lungs: Clear to auscultation bilaterally. No rales, rhonchi or wheezing on auscultation. No signs of labored breathing. Unremarkable egophony and tactile fremitus.
Cardiac: Normal S1/S2 and RRR. No murmur, JVD or carotid bruits appreciated.
Abdomen: soft, non-distended abdomen without any scars or lesions. Bowel sound present in all 4 quadrants. Non-tender to palpation in all quadrants. No guarding, rebound tenderness or sign of ascites.
GU: No masses or lesions on vulva or vaginal introitus. No signs of inflammation, discharge or erythema on vaginal mucosa or cervix. No cervical motion tenderness. Small and mobile uterus. Adnexa without masses or tenderness.
Rectal:. No lesions, fissures, hemorrhoids or stool in rectal vault. Good sphincter tone. Negative guaiac.
Extremities: Full passive and active ROM in upper and lower extremities bilaterally. 2+ pulses in upper and lower extremities. No sign of edema, muscle atrophy or muscle atrophy. Neurology: A&O x 3. Intact finger to nose test. Intact rapid alternating movement and heel-to-shin test. Intact sensation in UE and LE bilaterally. Muscle strength 5/5 in UE and LE. Cranial intact 2-12. Unremarkable gait and negative Romberg test. No signs of asterixis. Patellar and ankles reflexes 2+ bilaterally.
DDX
1. Polycystic ovarian syndrome
2. Ovulatory dysfunctions
3. Uterine polyps
4. Leiomyoma
5. endometritis
Labs
TSH 2.36
FSH 5.19
LH 11.10
CBC
Hgb 6.8 MCV 59.5 MCHC 26.1 WBC 12.6 Platelet 458
Hct 25.9 MCH 15.5 RDW 23.8 RBC 4.38 neutrophil 8.8 lymphocytes 29.3
Anisocytosis 2+
Poikilocytosis 1+
Hypochromia 2+
Assessment/plan: Ms. D is a 20 y/o Indian American female with PMHx of asthma presented to the office with complaints of irregular periods since her menarche likely due to ovarian dysfunctions or PCOS.
1. Microcytic anemia
-pt was called and advised to go to the nearest emergency room for blood transfusion due Hgb 6.8. Pt has not returned to the office for follow-up.
-ferrous sulfate delayed release 325 MG 1 tab TIDx90 days
-Vitamin C 500mg 1 tab daily x 90 days.
2. Abnormal uterine bleeding
-GYN referral for possible abdominal ultrasound, further work-up and OCP prescription.
Article Summary
Metformin or Oral Contraceptives for Adolescents With Polycystic Ovarian Syndrome: A Meta-analysis.
Al Khalifah RA, Florez ID, Dennis B, Thabane L, Bassilious E.
● This is a meta-analysis of 4 RCTs with a total sample size of 170 patients. This study was published in 2016, and its journal is currently indexed by Medline.
● The main objective was to determine the effectiveness of metformin and OCP at ameliorating menstrual cycle, hyperandrogenism and metabolic features of polycystic ovarian syndrome in adolescents.
● The initial total sample size was 231 patients of which 170 were randomly assigned to a metformin and an OCP group. Thirty-six patients did not complete the follow-up phase.
● The primary outcomes were menstrual regulation and hirsutism scores. Secondary outcomes included acne score, prevalence of dysglycemia, BMI, total testosterone and lipid profile.
Results:
● In terms of menstrual regulation, one study found better menstrual regulation with OCP, while the rest of the studies favored menstrual regulation in the metformin groups (WMD -0.15)
● In terms of hirsutism, there was not a significant difference between the metformin and OCP groups according to three studies (WMD 0.54, P= 0.5).
● In terms of acne scores, a significant difference was observed between the groups with greater improvement in the OCP group (WMD 0.3, P= 0.02) as per one study.
● Better results were observed in the metformin groups as compared to the OCP group in terms of dysglycemia prevalence as per 2 studies (RR 0.27, P=0.01)
● In terms of BMI, a significant difference was observed between the groups with better results among the metformin group as compared to OCP group (WMD -4.02, P<0.001).
● No significant difference was found in testosterone levels among the groups (WMD 0.74, P=0.1)
● No significant difference was found in triglyceride, and HDL levels among the groups, however, a significant difference was observed in the total cholesterol and LDL levels among the groups in favor of metformin (WMD-43.23, P<0.001, WMD -35.50, P=0.002)
In conclusion
● This study found that metformin and OCP can provide similar outcomes at improving triglyceride, HDL levels and hirsutism. OCPs were found to be better at regulating menstrual cycle and acne, while metformin provided better BMI reduction, and total cholesterol/LDL control as well as reduction in dysglycemia prevalence. Results must be interpreted with caution, since this meta-analysis included a limited number of studies with very low to low quality.
End of Rotation Self-reflection: RT
- Types of patients you found challenging in this rotation and what you learned about dealing with them During this rotation, I was surprised to see several cases of schizophrenia and bipolar disorder. I found patients with schizophrenia very challenging, because the information they provide can be very unreliable. Most of these patients presented to the office for routine check-up of chronic diseases such as hypertension and diabetes. Assessing for symptoms and addressing new complaints unrelated to their psychiatric condition was very difficult; some of these patients were denying any symptoms or were answering “yes” to every question I asked them. Because of their psychiatric condition, new health problems might go undiagnosed and untreated. In addition, it might be harder for these patients to comply with their treatment. I remember one patient that was reluctant to continue his blood pressure and diabetes medication as well as to be examined in the office. One thing that I learned when dealing with these patients is to validate their point and to let them know that we understand them. This approach I found makes them feel more comfortable. Another thing that I learned is to ask for permission before doing a physical exam, checking their glucose, doing their vitals, so they know you are not invading their space.
- Improving my previous skillsIn this rotation, I was able to improve my venipuncture technique. This primary care office has a small lab, so I had the opportunity to perform venipuncture for patients coming for annual physical, pre-employment physical, diabetic routine check-up or any other complaint that needed blood-work. One of my weaknesses when doing blood draws was to palpate and select a vein that was not visible. I was able to do a little more than 24 venipuncture. Now, I do feel much more comfortable when palpating and aiming with the needle for those veins. I was also able to do 4 IM injections, which I didn’t have the opportunity to perform those in previous rotations.
- How could the knowledge I’ve gained here be applicable in other rotations/disciplines? Although we learned in pharmacology class that headaches can be a side effect of calcium channel blockers, you get to remember medication side effects when you actually see these cases in practice. Because the community around this primary care office is African American, most of the patients are prescribed hydrochlorothiazide or amlodipine for blood pressure control and ACEis for patients with diabetes. However, some patients came with complaints of headache shortly after being placed on amlodipine, the reason why the doctor switched them to a different blood pressure medication. As per the doctor, headache is a common side effect of calcium channel blocker. I also saw a few cases of dizziness and bradycardia probably caused by beta-blockers like metoprolol. From these cases, I learned that it is important to consider side effects of medication as potential differential whenever applicable, especially in elderly patients on multiple medications.
Evaluation Reflection
For my first site evaluation, I presented a 31 y/o African American female with PMHx of dermoid ovarian tumor, ovarian cyst and uterine fibroids who presented to the office for follow-up results. On a previous visit, pt had an annual physical exam as well as a complaint of RUQ abdominal pain and abnormal vaginal bleeding for a total of 14 days. Laboratory results showed elevated liver enzymes indicating possible cholecystitis and abnormal CBC and UA correlating with asymptomatic microcytic anemia and UTI. In our discussion, we touch on possible differential diagnosis including the likelihood of malignancy in this patient due to the previous hx of ovarian dermoid tumor and abnormal vaginal bleeding. We also discussed some antibiotics that can be used for UTI as well as alternative work-up for this patient.
For the second site evaluation, I presented a 20 y/o Indian American female with PMHx of asthma presented to the office with complaints of irregular periods since her menarche and periods regulated with weight control. Laboratory results showed a Hgb of 6.8. Patient was called and referred to the ER for possible blood transfusion. In our discussion, Prof. Malavet highlighted that for young , healthy and asymptomatic patients, like this one, blood transfusion might not be needed. For this case, we agreed that it could be a possible presentation of polycystic ovarian syndrome. For this case, I presented a meta-analysis studying the effectiveness of OCP and metformin at improving menstrual cycle, hyperandrogenism and metabolic features of polycystic ovarian syndrome in adolescents. This study found that OCPs are better for menstrual regulation and acne, while metformin provided better BMI reduction, and total cholesterol/LDL control as well as reduction in dysglycemia prevalence.
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