Assignment task:
Case #1. Diana.
History of Present Illness (HPI): Diana is a 48-year-old Hispanic G4P1031. She presents to your office as a new patient for GYN visit. Her last visit to a gynecologist was 12 years ago after the birth of her daughter. Her periods come at variable intervals, sometimes every three months, other times twice in a month. Flow varies from minimal spotting to heavy bleeding requiring pad changes every hour. She reports dysmenorrhea with her periods that is relieved with ibuprofen. She reports a 30-pound weight gain over the past 10 years.
Prior medical history: Gallstones. Prior surgical history: Lap cholecystectomy (2008)
Current medications: None. Allergies: None
OB- GYN History: Surgical TOP x 3. C-section x 1 at full term for arrest of descent. Menarche age 13, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day, until recently. No history of sexually transmitted infections (STDs). No history of abnormal pap smears. Last pap was 12 years ago, reported normal. HIV negative.
LMP: 2 weeks ago - heavy with clots and lasted 10 days. Contraception history: None.
Social history: Lives with husband and daughter. Stay at home mom. Denies ETOH or recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.
Family history: Mother s/p hysterectomy for fibroids, sister with diabetes mellitus.
Review of Systems (ROS): Negative except as noted in HPI.
Physical Exam (PE)
VS: BP: 155/80, P: 99, RR: 18, T: 98.4, Weight: 206 lbs., Height 66 in, BMI 33.2 kg/m2
- General: NAD, well-appearing, obesity in female
- Abd: Soft, NT/ND, no masses/HSM
- GU: No lesions; normal vaginal mucosa; no CMT; no uterine/adnexal tenderness; uterus 8-week size; no adnexal masses
- Ext: Good CMS, 1+ edema b/l
Case #2. Barbara.
History of Present Illness (HPI): Barbara is a 73-year-old Caucasian G2P2002. She is a retired schoolteacher, lives alone. She complains of 2-year history of ten episodes of daytime frequency with small frequent voids, a constant desire to urinate, and nocturia x 3 every night, resulting in poor sleep. More recently, symptoms have worsened and now include a sudden urge to void and occasional urinary incontinence with structured physical activity. She changes pads three times a day and complains of superficial dyspareunia. She denies OAB meds or hormone replacement therapy in the past. She complains of mild constipation and has had three lower urinary tract infections (UTIs) in the last 12 months.
Prior medical history: HTN, UTI. Prior surgical history: Appendectomy (1998)
Current medications: Cardura 2mg daily, furosemide 20mg daily. Allergies: Penicillin
OB- GYN History: Forceps-assisted VD x 2. Menarche age 14, normal throughout life. No history of sexually transmitted infections (STDs). Last pap smear age 67 years, normal.
LMP: Approximately 25 years ago. Contraception history: None.
Social history: Lives alone. Retired schoolteacher. ETOH: 1-2 glasses red wine nightly. No recreational drug use. Never smoked. Plays bingo 3 times weekly and participates in structured physical activity (pickle ball and Pilates) 3-4 times weekly.
Family history: Mother (deceased age 79)- CVA. Father (deceased age 72) - MI/ASHD
Review of Systems (ROS): As noted in HPI.
Physical Exam (PE)
VS: BP: 133/68, P: 68, RR: 16, T: 97.3, Weight 134lbs, Height 64 inches, BMI 23 kg/m2
On physical exam, marked urogenital atrophy is noted, no ulcerations noted. Positive urine leakage when asked to cough. There is uterine descent into vagina up to the introitus, bladder is noted just at the opening of the vagina, and rectum noted halfway to hymen.
Case #3. Vivian.
History of Present Illness (HPI): Vivian is an 88-year-old Caucasian female brought into the office by her caregiver. Complains of dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations. The caregiver reports a history of disturbed night sleep, with hallucinations of spiders crawling in bed, followed by agitation, lethargy, and poor oral intake the next morning. Other symptoms include increased urinary frequency, dysuria, mild fever, and lower abdominal pain. The caregiver also reports that Vivian had been treated for suspected UTI twice in the last 12 months.
Prior medical history: HTN, CKD stage 2, diverticular disease, vesicovaginal fistula (newly diagnosed), previous indwelling urinary catheter, osteoporosis, left femur fracture s/p fall.
Prior surgical history: Left Total Hip Replacement (2012).
Current medications: Olmesartan 20mg daily, Alendronate 70mg weekly, Vitamin D3 5,000 IU daily.
Allergies: None
Social history: Never smoked or drank alcohol. Lives alone with 24-hour caregiver after husband died 3 years ago and she had a fall that resulted in femur fracture.
Family history: Mother deceased (age 74)- breast cancer. Father deceased (age 70)- CVA.
Review of Systems (ROS): As noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 109, RR: 17, T: 98.9, Weight: 132 lbs., Height 65 inches, BMI 22 kg/m2
- General: Restless, oriented to person and place
- Cardio: S1 and S2 heart sounds in regular rhythm with no murmurs or extra sounds.
- Resp: Lungs CTA, no wheezing or rhonchi. Nonlabored breathing
- Abd: Soft, NT/ND, no masses/HSM, no suprapubic tenderness
- GU: No CVA tenderness, urine dip in office revealed pH 6.0, 3+ leukocytes, positive nitrites
- Ext: Good CMS, no peripheral edema
Case #4. Stephanie.
History of Present Illness (HPI): Stephanie is a 15-year-old female G0 who presents to the office with her mother. She c/o heavy bleeding during her periods, anxiety, and mood swings, which had been occurring for the past 4 months. Her symptoms usually occur a few days before the onset of her menses and improve by day 3. She uses 2 pads every 1-2 hours and sometimes needs to double up on the pads. She also c/o severe bloating, pelvic pain, and back pain during her periods. She has missed numerous days of school due to her symptoms, and lacks interest in usual daily activities, staying in bed all day. Around 2 months ago, she was seen by an adolescent psychiatrist and was diagnosed with major depression and started on sertraline 50mg once daily. She has refused to take the medication because she rejects the diagnosis of depression. She states that she knows she is not depressed and is angry that nobody believes her.
Prior medical history: Questionable depression. Prior surgical history: None
Current medications: None. Allergies: Sulfa.
OB- GYN History: Menarche age 12, cycle length was 5-7 days- frequency every 28 days- 3 pads per day, until the past 4 months.
LMP: 1 week ago. Contraception history: None
Social history: Lives with her parents. She is an only child. Denies EtOH, smoking, or recreational drug use. Sexually active once (vaginal) - 1 year ago with same partner- none since. Participates in sports: basketball
Family history: Mother alive and well, Father with diabetes
Review of Systems (ROS): Unremarkable with exception of as noted in HPI.
Physical Exam (PE)
VS: BP: 122/74, P: 64, RR: 16, T: 97.8 Weight: 146 lbs., Height: 63 inches, BMI 26.2
General Examination: Well developed, well nourished, in no acute distress.
Psych: alert and oriented, cooperative with exam, appears frustrated.
Abdomen: Soft, NTND, no masses
Gynecological: EXTERNAL EXAM: normal, appropriate hair distribution, no erythema, no skin discoloration, no lesions. SPECULUM/INTERNAL EXAM: Cervix: normal appearance, no lesions, no bleeding/discharge, no cervical movement tenderness, nulliparous. UTERUS: normal size, shape, and consistency, normal mobility, nontender. ADNEXA: no masses or tenderness bilaterally.
Outline Subjective data.
Identify data provided in your chosen case and any additional data needed.
Outline Objective findings.
Identify findings provided in your chosen case and any additional data needed.
Identify diagnostic tests, procedures, laboratory work indicated.
Describe the rationale for each test or intervention with supporting references.
Distinguish at least three differential diagnoses.
Describe the rationales for your choice of each diagnosis with supporting references.
Identify appropriate medications, treatments or other interventions associated with each differential diagnosis.
Describe rationales and supporting references for each.
Explain key Social Determinants of Heath (SDoH) for your chosen case.
Describe collaborative care referrals and patient education needs for your chosen case.
Describe rationales and supporting references for each.