CC : “I want to start birth control.”
HPI: M is a 36 year-old Caucasian female who presents to clinic to inquire about contraception. She has been in a monogamous relationship with her boyfriend for the past 1.5 years. She finds condoms to be cumbersome and a couple of weeks ago the condom broke. She has 2 children and her boyfriend has 3- she does not want any more children. Life is hectic right now as both her children are involved in several after school activities and they are in the process of moving into her boyfriend’s house.
PMH: Allergic rhinitis, asthma, migraine headache (with aura), acne
FH: Mother and father A&W; brother passed away at age 19 in a motor vehicle accident
SH: divorced; 2 children (ages 8 & 10); real estate agent; (+) tobacco (5 cigarettes/day), (-) illicit drugs; (+) alcohol (2-3 glasses of wine/week)
ALL: NKDA
Medications: Advair 250/50, inhale 1 puff PO BID (asthma)
Differin 0.1% gel, apply to affected area once daily at bedtime for acne
Loratadine 10 mg PO daily PRN seasonal allergies
Proair HFA, inhale 1-2 puffs PO Q4-6H PRN SOB (asthma)
Sumatriptan 25 mg PO at the first sign of migraine; may take a second dose 2 hours later if no relief
ROS: Denies headache, fatigue, SOB, chest pain, abdominal pain, N/V/D, dysuria, vaginal discharge; swelling, pain, or edema in the extremities; (+) numerous comedones on face
Physical exam:
VS: BP 110/70 mmHg, HR 76 bpm, RR 17 bpm, T 98.6°F, Wt 182 lb, Ht: 5’5”
Skin: ~12 open comedones on nose, 8 closed comedones on chin, 2 closed comedones on forehead; no evidence of scarring; skin is non-oily
HEENT: No carotid bruits; PERRLA; EOMI; (-) hemorrhages, exudates or AV nicking
Neck: (-) JVD
CV: RRR; normal S1 and S2; no S3, S4, murmurs, rubs, or bruits
Lungs: CTA
Abd: Soft, NTND, central obesity, normal BS
GU: Normal vaginal exam without tenderness or masses
Ext: (+) distal pulses
Neuro: A&O x 3; CN II-XII intact
Labs (fasting):
Na 140 mEq/L Hgb 13.0 g/dL T. cholesterol 170 mg/dL
K 3.7 mEq/L Hct 38% TG 90 mg/dL
Cl 100 mEq/L Plt 300 x 103/mm3 HDL 45 mg/dL
CO2 25 mEq/L WBC 7.0 x 103/mm3 LDL 107 mg/dL
BUN 12 mg/dL
SCr 1.0 mg/dL ALT 24 IU/L
Glucose 115 mg/dL AST 26 IU/L
A1c 5.8%
eGFR 63 mL/min/1.73m2
Two Months Later
Two months later, M is admitted to the hospital with an asthma exacerbation. While in the hospital, she is treated with methylprednisolone 40 mg IV daily.
Three Years Later
Three years later, M, a 39 year-old Caucasian female, presents to the clinic complaining of feeling tired and cold all the time. She has no energy- she has really been struggling and doesn’t know if there is anything she can do. Her provider sends her for labs.
Physical Exam
Gen: Well-appearing, NAD
VS: BP 118/74; HR 70; RR 18 bpm, T 36.4 C Ht 5’5”, Wt 185 lbs
Skin: Dry appearing skin and scalp; (-) rashes or lesions
HEENT: PERRL, EOMI
Neck: (-) thyroid nodules or goiter; (-) lymphadenopathy
Lungs: CTA bilaterally
Heart: RRR, normal S1, S2; (-) S3 or S4
Abd: Soft, NTND
GU/Rect: deferred
Ext: 2+ DP pulses bilaterally
Neuro: A&Ox3; CN II-XII intact; DTRs 2+, symmetric
Labs (fasting):
Sodium 138 mEq/L TSH 15.8 mIU/L
Potassium 4.3 mEq/L Free T4 0.1 mcg/dL
Chloride 98 mEq/L
Bicarbonate 25 mEq/L
BUN 9 mg/L
SCr 0.9 mg/L
Glucose 110 mg/L
Thirty Years Later
PMH: HTN x 7 years, type 2 DM x 5 years, allergic rhinitis, asthma, migraine headache (with aura)
FH: Mother ¯ 78 – colon cancer, father ¯ 82 – complications of diabetes; 2 adult children & 3 adult step-children A&W
SH: Married; real estate agent; (+) tobacco (5 cigarettes/day), (-) illicit drugs; (+) alcohol (1-2 glasses of wine/week)
Meds: Pt reports adherence to the following medications:
Advair 500/50, inhale 1 puff PO BID (asthma)
Amlodipine 10 mg PO daily (HTN)
Aspirin 81 mg PO daily
Atorvastatin 40 mg PO daily (lipids)
Levothyroxine 125 mcg PO daily
Loratadine 10mg PO daily PRN seasonal allergies
Metformin 1000 mg PO BID
Pioglitazone 30 mg PO daily
Proair HFA, inhale 1-2 puffs PO Q4-6H PRN SOB (asthma)
Sumatriptan 25 mg PO at the first sign of migraine; may take a second dose 2 hours later if no relief
ALL: NKDA
Immunizations: Influenza vaccine (10/2002)
ROS: Denies fatigue, polyuria, polydipsia, blurry vision, chest pain, dizziness, shortness of breath.
Physical Exam:
VS: BP 136/84 mmHg, HR 76 bpm, RR 17 bpm, T 98.6°F, Wt 230 lb, Ht: 5’5”
HEENT: No carotid bruits; PERRLA; EOMI; (-) hemorrhages, exudates or AV nicking
Neck: (-) JVD
CV: RRR; normal S1 and S2; no S3, S4, murmurs, rubs, or bruits
Lungs: CTA
Abd: Soft, NTND, central obesity, normal BS
GU: Deferred
Ext: (+) distal pulses, +1 pitting edema
Neuro: A&O x 3; CN II-XII intact
Labs (fasting):
Na 141 mEq/L Total cholesterol 178 mg/dL Vitamin D 22 ng/mL
K 4.0 mEq/L TG 165 mg/dL
Cl 102 mEq/L HDL 42 mg/dL
CO2 24 mEq/L
BUN 19 mg/dL AST 26 IU/L
SCr 1.1 mg/dL ALT 24 IU/L
Glucose 120 mg/dL
A1c 7.3% eGFR 49 mL/min/1.73m2
UA: (-) ketones, (-) protein, (-) glucose
Albumin:creatinine 22 mcg/mg
M was sent to get screened for osteoporosis. She returns a month later to discuss her results.
DXA of lumbar spine (L2-4): T-score:-1.6 SD; Z-score:-0.5 SD
DXA of right femoral neck: T-score:-2.2 SD; Z-score:-0.4 SD
DXA of left femoral neck: T-score -1.9 SD; Z-score: -0.4SD
X-Ray Spine: no fractures noted
FRAX: Major osteoporotic 12%; hip fracture 3.7%
HPI: M is a 36 year-old Caucasian female who presents to clinic to inquire about contraception. She has been in a monogamous relationship with her boyfriend for the past 1.5 years. She finds condoms to be cumbersome and a couple of weeks ago the condom broke. She has 2 children and her boyfriend has 3- she does not want any more children. Life is hectic right now as both her children are involved in several after school activities and they are in the process of moving into her boyfriend’s house.
PMH: Allergic rhinitis, asthma, migraine headache (with aura), acne
FH: Mother and father A&W; brother passed away at age 19 in a motor vehicle accident
SH: divorced; 2 children (ages 8 & 10); real estate agent; (+) tobacco (5 cigarettes/day), (-) illicit drugs; (+) alcohol (2-3 glasses of wine/week)
ALL: NKDA
Medications: Advair 250/50, inhale 1 puff PO BID (asthma)
Differin 0.1% gel, apply to affected area once daily at bedtime for acne
Loratadine 10 mg PO daily PRN seasonal allergies
Proair HFA, inhale 1-2 puffs PO Q4-6H PRN SOB (asthma)
Sumatriptan 25 mg PO at the first sign of migraine; may take a second dose 2 hours later if no relief
ROS: Denies headache, fatigue, SOB, chest pain, abdominal pain, N/V/D, dysuria, vaginal discharge; swelling, pain, or edema in the extremities; (+) numerous comedones on face
Physical exam:
VS: BP 110/70 mmHg, HR 76 bpm, RR 17 bpm, T 98.6°F, Wt 182 lb, Ht: 5’5”
Skin: ~12 open comedones on nose, 8 closed comedones on chin, 2 closed comedones on forehead; no evidence of scarring; skin is non-oily
HEENT: No carotid bruits; PERRLA; EOMI; (-) hemorrhages, exudates or AV nicking
Neck: (-) JVD
CV: RRR; normal S1 and S2; no S3, S4, murmurs, rubs, or bruits
Lungs: CTA
Abd: Soft, NTND, central obesity, normal BS
GU: Normal vaginal exam without tenderness or masses
Ext: (+) distal pulses
Neuro: A&O x 3; CN II-XII intact
Labs (fasting):
Na 140 mEq/L Hgb 13.0 g/dL T. cholesterol 170 mg/dL
K 3.7 mEq/L Hct 38% TG 90 mg/dL
Cl 100 mEq/L Plt 300 x 103/mm3 HDL 45 mg/dL
CO2 25 mEq/L WBC 7.0 x 103/mm3 LDL 107 mg/dL
BUN 12 mg/dL
SCr 1.0 mg/dL ALT 24 IU/L
Glucose 115 mg/dL AST 26 IU/L
A1c 5.8%
eGFR 63 mL/min/1.73m2
Two Months Later
Two months later, M is admitted to the hospital with an asthma exacerbation. While in the hospital, she is treated with methylprednisolone 40 mg IV daily.
Three Years Later
Three years later, M, a 39 year-old Caucasian female, presents to the clinic complaining of feeling tired and cold all the time. She has no energy- she has really been struggling and doesn’t know if there is anything she can do. Her provider sends her for labs.
Physical Exam
Gen: Well-appearing, NAD
VS: BP 118/74; HR 70; RR 18 bpm, T 36.4 C Ht 5’5”, Wt 185 lbs
Skin: Dry appearing skin and scalp; (-) rashes or lesions
HEENT: PERRL, EOMI
Neck: (-) thyroid nodules or goiter; (-) lymphadenopathy
Lungs: CTA bilaterally
Heart: RRR, normal S1, S2; (-) S3 or S4
Abd: Soft, NTND
GU/Rect: deferred
Ext: 2+ DP pulses bilaterally
Neuro: A&Ox3; CN II-XII intact; DTRs 2+, symmetric
Labs (fasting):
Sodium 138 mEq/L TSH 15.8 mIU/L
Potassium 4.3 mEq/L Free T4 0.1 mcg/dL
Chloride 98 mEq/L
Bicarbonate 25 mEq/L
BUN 9 mg/L
SCr 0.9 mg/L
Glucose 110 mg/L
Thirty Years Later
PMH: HTN x 7 years, type 2 DM x 5 years, allergic rhinitis, asthma, migraine headache (with aura)
FH: Mother ¯ 78 – colon cancer, father ¯ 82 – complications of diabetes; 2 adult children & 3 adult step-children A&W
SH: Married; real estate agent; (+) tobacco (5 cigarettes/day), (-) illicit drugs; (+) alcohol (1-2 glasses of wine/week)
Meds: Pt reports adherence to the following medications:
Advair 500/50, inhale 1 puff PO BID (asthma)
Amlodipine 10 mg PO daily (HTN)
Aspirin 81 mg PO daily
Atorvastatin 40 mg PO daily (lipids)
Levothyroxine 125 mcg PO daily
Loratadine 10mg PO daily PRN seasonal allergies
Metformin 1000 mg PO BID
Pioglitazone 30 mg PO daily
Proair HFA, inhale 1-2 puffs PO Q4-6H PRN SOB (asthma)
Sumatriptan 25 mg PO at the first sign of migraine; may take a second dose 2 hours later if no relief
ALL: NKDA
Immunizations: Influenza vaccine (10/2002)
ROS: Denies fatigue, polyuria, polydipsia, blurry vision, chest pain, dizziness, shortness of breath.
Physical Exam:
VS: BP 136/84 mmHg, HR 76 bpm, RR 17 bpm, T 98.6°F, Wt 230 lb, Ht: 5’5”
HEENT: No carotid bruits; PERRLA; EOMI; (-) hemorrhages, exudates or AV nicking
Neck: (-) JVD
CV: RRR; normal S1 and S2; no S3, S4, murmurs, rubs, or bruits
Lungs: CTA
Abd: Soft, NTND, central obesity, normal BS
GU: Deferred
Ext: (+) distal pulses, +1 pitting edema
Neuro: A&O x 3; CN II-XII intact
Labs (fasting):
Na 141 mEq/L Total cholesterol 178 mg/dL Vitamin D 22 ng/mL
K 4.0 mEq/L TG 165 mg/dL
Cl 102 mEq/L HDL 42 mg/dL
CO2 24 mEq/L
BUN 19 mg/dL AST 26 IU/L
SCr 1.1 mg/dL ALT 24 IU/L
Glucose 120 mg/dL
A1c 7.3% eGFR 49 mL/min/1.73m2
UA: (-) ketones, (-) protein, (-) glucose
Albumin:creatinine 22 mcg/mg
M was sent to get screened for osteoporosis. She returns a month later to discuss her results.
DXA of lumbar spine (L2-4): T-score:-1.6 SD; Z-score:-0.5 SD
DXA of right femoral neck: T-score:-2.2 SD; Z-score:-0.4 SD
DXA of left femoral neck: T-score -1.9 SD; Z-score: -0.4SD
X-Ray Spine: no fractures noted
FRAX: Major osteoporotic 12%; hip fracture 3.7%
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