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Posted: October 2nd, 2022
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Reason for Seeking Care
“I feel weak and tired lately.”
HEALTH HISTORY
HPI
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B.S. is a 28 year old white female who reports a 2 month history of menorrhagia, intermenstrual bleeding, extreme fatigue, and weakness. Her menstrual period occurs every 28 days. Lately, she’s had 6 days of heavy flow and cramping. She denies abdominal distension and back pain. She reports that her energy level has not returned to normal since her last pregnancy.
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G5P5T5A0. Four pregnancies in past four years. Fourth child delivered via SVD four months ago. All deliveries were without complications. All children were born and remain healthy.
Three year history of osteoarthritis of the left knee. History of left knee trauma in MVA at age 9. Reports that she takes ibuprofen 3 tabs daily for pain. She has been taking it for 2.5 years. She recently doubled her daily dose due to increasing pain with decreased relief.
Three year history of HTN treated with antihypertensive medication.
No history of surgeries.
Family History
Father living, age 66, stable angina.
Mother living, 58, osteoarthritis.
Brother, 35, living with DM2 and hyperlipidemia.
Sister, 32, depression and hypothyroidism.
Paternal grandparents deceased, heart disease.
Maternal grandparents unknown due to adoption.
Children, aged 4 months, 12 months, 2-1/ years, 4 years, 9 years. All healthy.
Social History
Born in US to Greek immigrants.
Married, homemaker. Lives with husband of 10 years.
Denies smoking, alcohol intake, street drug use.
Lacto-ovo vegetarian x 5 years.
Admits to lack of regular exercise program, “although the kids keep me running all the time.”
ROS
Craves cold celery x 3 weeks
+ mild urinary urgency with incontinence
+ mild SOB with exertions, difficulty concentrating
Denies hematuria, hematemesis, hemoptysis, melena
Denies palpitations, history of cardiac or pulmonary disease
Medications
OTC ibuprofen 200 mg po 6x/day prn
OTC omeprazole 20 mg po QD
HCTZ 30 mg po BID
Denies vitamin, calcium, and iron supplements.
Allergies
Erythromycin causes upset stomach
ASA causes upset stomach
PHYSICAL EXAM
General Survey
Tired and pale looking white overweight female in NAD. Appears her stated age. Pleasant, cooperative, alert & oriented x3.
Vital Signs
T = 98.0 F; P = 140 and regular; RR = 17 and easy; BP = 100/40 (seated, right arm)
HT = 5’6”
WT = 173 lbs
Significant PE Findings
Skin pale, cool
Sclera bluish, conjunctiva pale
Oral mucous membranes pale
Tachycardic, systolic murmur heard best at RSB
Joint enlargement and limited ROM of left knee consistent with DJD.
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