- History
- Reason for Visit
Annual Well-woman examination
- Present Medical Status
JA is a new female patient, 52 years of age, of black American descent. Patient has decided to visit the clinic for her annual well-woman examination procedure.
- Family Medical and Health History
Patient’s maternal family has had a history of HTN (hypertension) and DM (Diabetes Mellitus, type unspecified and unrecalled); and a paternal family history of CA (Cancer) of the breast and colon. Both maternal and paternal family has no history of Kidney Diseases, Vascular, and Pulmonary Disorders.
- Diet and Nutritional Assessment
Patient is a vegetarian; prefers to eat vegetables over meats (both red and white). Patient consumes at least two glasses of fresh milk every day, one glass upon waking up and another glass before going to sleep. Patient has been on a vegetarian and two-glasses of milk diet for the past 12 years, since she was 40 years old. Patient takes two multivitamin (Centrum) capsules daily, the first one is taken after lunch and the second one after dinner. Patient does not take any form of pills such as estrogen (e.g. Premarin) and progesterone (e.g. Provera).
- Physical, Social, and Environmental History Assessment
Patient is a non-smoker and non-alcoholic beverage drinker; has a relatively sedentary lifestyle. Daily physical activities include watching television, helping the family do some simple household chores. Patient lives in a bungalow type of house with her son and her son’s family, and a dedicated caregiver.
- Physical Examination (Objective Findings)
- Height: 5’ 6” cm
- Weight: 159 lbs.
- Body Mass Index: 20
- Gender: Female
BMI Table
- Blood Pressure:
- before: 130/90 mmHg
- after: 130/100 mmHg
- Interpretation: Pre-hypertensive
- Recommendation: Refer to cardiac specialist for examination and possible prescription of maintenance medications for HTN.
3
3
- If patient is under the age of 55, birth control methods used
Intra-Uterine Device for 20 years; well-maintained by quarterly visits to an OB/Gynecologist
- First year of menstruation
11 years old
- Age of Menopause
48 years old, 4 years ago
- Tests and Procedures
- Mammograms
- No pertinent findings, (-) lumps on (B) sides of the breast
- Pap smear
- No pertinent findings
- Review of Systems
- Skin
- No pertinent findings
- Cardiovascular
- No pertinent findings
- Pulmonary
- No pertinent findings
- Digestive
- No pertinent findings
- Reproductive
- No pertinent findings
- Musculoskeletal
- No pertinent findings
- Recommended Immunizations
- Influenza Vaccine (recommended, annually)
- Tetanus, diphtheria, and pertussis vaccines (once every ten years)
- Herpes zoster (shingles) vaccine
- Meningococcal vaccine
- Past Reproductive Health-related Problems
Patient did not have any form of reproductive health-related problems such as abnormal pap smears, abnormality in colposcopy, biopsy, and surgical procedures; high blood pressure complications and high blood cholesterol complications; blood clots, migraine headaches, and cancer; and abdominal and pelvic dysfunction special tests. Patient also stated that she did not have any previous problems associated with her birth control methods during her non-menopausal years; bleeding between periods or since she stopped having periods (menopause); pain during, and immediately after intercourse; problems in being interested in or enjoying intercourse; or any new lumps or any forms of irregular enlargements in the breasts; abnormal changes in the firmness, size, and consistency of stools; change in appearance (e.g. color) of a mole; occurrences of unexplained headaches; presence of pain in the abdominal, pelvic, low-back, chest areas, and joints; trouble in sleeping; depression and anxiety-related symptoms; conflicts in family and social relationships.
Patient had a history of fracture, specifically a (L) hip fracture secondary to a minor trauma two years ago. Patient has a paternal family history of osteoporosis. Patient reported of an unexplained height loss which started to occur four years ago. Patient has no records of bone density test results. Patient does not currently take steroids (corticosteroids) and other medications for thyroid disorders.
Overall Impression, Counseling and Tx Plan
This is the first time that JA has been subjected to a well woman examination procedure. In summary, she presents with a fairly healthy body for a typical person of her age. Some of the most pertinent findings include the fact that she is obese with a BMI of 30 which is the borderline for obesity . This may contribute to her present and future reproductive health as most obese women tend to suffer from depression and other psychological and health problems. Obesity also significantly increases a woman’s risks of developing metabolic and cardiovascular diseases such as HTN (patient has a maternal family history of HTN), and DM. Another pertinent finding is the patient’s history of hip fracture due to a minor trauma and reports of unexplained loss of height. These two findings can be considered as indicative signs of osteoporosis . The patient has been unable to undergo any form of bone density scans or tests. Bone density scans measure the density of the patient’s bones, particularly the weight bearing bones . A low bone density may suggest or confirm whether the patient has osteoporosis or porous bones or otherwise.
Recommendations
As the medical practitioner in charge, I would recommend that the patient immediately undergo a bone density scan. A Dexa Scan, for example, can be easily performed by most medical centers and clinics that have their own orthopedic departments. The patient should also be advised to come back immediately to us so that the results of the bone scan can be interpreted and should the findings point to our initial prediction that her hip fracture two years ago was partly caused not just by the minor trauma but also by the significant decrease in her hip bone density as a secondary effect of osteoporosis, the patient shall be referred to an appropriate specialist.
The information that the patient provided during the history taking can be used to determine whether more specific and invasive diagnostic and examination procedures would be necessary to ensure the patient’s current health condition. Based on the information gathered during the history taking, exams such as Pap smear, intensive inspection of the female genitalia, bimanual exams, and speculum examinations, may be unnecessary. Although the conduction of these examination procedures may help improve the accuracy and reliability of the physician’s initial impression about her current reproductive health conduction , for example, such tests are not absolutely necessary because based on the history taking information provided by the patient, she has a rather healthy reproductive system. Signs and symptoms such as pain, reports of discoloration and discomfort (e.g. pressure ulcer on the outer vaginal opening or any area near the pelvis and pubis) may however indicate that such manual and slightly invasive procedures be performed for confirmation. The recommendation remains the same for this patient—that it is unnecessary for her to undergo such procedures. However, if she does not feel uncomfortable to undergo such tests in any way, then we may recommend her to undergo such tests for confirmation.
- Physical Exam Results
- (+) Osteoporosis as evidenced by low bone density finding in the Bone Density Scan
Education on Treatment Plan
- Joint Protection and Energy Conservation
- The treatment plan should focus on joint protection and energy protection to reduce further injuries because osteoporosis among menopausal women cannot be reversed. Calcium absorption in the bones generally stops during early to mid-20s and so in the case of the patient, her condition, Osteoporosis, can already be considered irreversible.
References
American Congress of Obstetricians and Gynecologists. (2012). Committee Opinion on Well Woman Visit. ACOG, http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Gynecologic%20Practice/Well-Woman%20Visit.aspx.
CDC. (2014). BMI. Centers for Disease Control and Prevention, http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html?s_cid=tw_ob064.
Cummings, S., Browner, W., Cummings, S., & Black, D. (1993). Bone Density at Various Sites for Prediction of Hip Fractures Abstract. The Lancet.
Norton, M., & Gamble, C. (2001). Bone Classification: An objective scale of bone density using the Computerized Tomography Scan Abstract. Clinical Oral Implants Research.
