Reference no: EM132625096
Assignment: Topic 2: Abdominal Pain and Weight Gain
Subjective: Patient Annett, a 28-year-old female, presents to the primary care practice for an initial visit. She presents with two major concerns. First she is concerned because she was told she had gallstones by ultrasound and was advised by another primary care provider (PCP) that she needed her gallbladder removed. She has had several bouts of abdominal pain and some dyspepsia, but not nausea, vomiting, or any other gastrointestinal symptoms. She points to an area in her abdomen that has been painful, especially when she eats high-fat foods. She has no other gastrointestinal complains.
Her second complaint is weight gain. Her diet has not changed over the past few years; however she has noticed a change in the way her clothes fit as well as a 15 pound weight gain over the past year. Also, over the last year, she has had irregular menses. She often "skips months," and she reports only 7 cycles of menstruation over the past year. When she does have her period, "it lasts for over 2 weeks." At one point she did not have a period for 3 months, and she thought that she might be pregnant. Her review of systems is negative except for increased hair growth across the sides of her face, her chin, and the middle of her chest, arms, and upper thighs, which she has had since she was an adolescent. She also complains of acne.
Further review of systems reveals no dizziness, no headache, no problems with her vision, no ringing in her ears; she is not short of breath. She has not complaints of cough, no palpitations, no chest pain. She has no genitourinary complaints. She has no musculoskeletal complaints. She has no weakness, no paresthesia, and no numbness or tingling of the extremities.
Past medical history: Non contributory
Past surgical history: None.
Family medical history: Her mother was born in Brazil and reports not tobacco, alcohol, or substance abuse. She drinks 1 cup of coffee daily and lives at home with her mother, brother, and sister in a single-family home in a suburban town. She works full time as an administrative assistant and is a part-time student finishing her bachelor's degree in science at a state college. She has a network of friends and family and her hobbies include traveling and theater. She is currently in a sexual relation with one partner and does not practice any form of contraception. Her LMP was 2 months ago and her last Pap smear was 2 years ago and negative.
Medication and allergies: She has not medication allergies but reports allergies to pork and cats. She is not on any regular medications but takes Tylenol 2 tablets as needed for headeache. Her immunizations are all up to date.
Objective: Vital signs are within normal limits with a blood pressure of 110/80 and a temperature of 98.2 F. Pulse is 76 and regular, RR 18, Ht. 62 inches, weight 200lbs (BMI 36.6). She is a well-developed, obese female who is in no acute distress. She is coherent, alert, and pleasant.
Skin: She has fine dark hair on her chin and on the sides of her face. There is increased hair growth on her forearms, sternal area, and upper thighs. Acne is present on her forehead and lateral cheeks bilaterally.
Neck: Goiter, thyroid is palpable, non-tender; no nodules are palpable or appreciated. Neck is supple and without lymphadenopathy.
Respiratory: Lungs clear to auscultation (CTA), chest symmetrical.
Cardiac: Regular rate and rhythm (RRR), with S1 and S2 present without murmurs, rubs, or gallops.
Abdomen: Obese soft; bowel sounds are present; and there is tenderness in the epigastric area. Liver and spleen are nonpalpable.
Musculoskeletal: Extremities are without edema. There is full range of motion and good strength. Carotid, femoral, dorsalis pedis, and post tibial pulses are all 2+.
Neurological: DTR's are 2+ in the biceps, triceps, brachioradials, patella, and Achilles. Cranial nerves II-XII are grossly intact.
1. List 3 differential diagnoses (rule in or out according to history, lab work, or exam).
2. Develop appropriate evidenced-based treatment plan.
3. Educate women of all ages on women's health issues.