Rotation8 Typhon Patient Encounter

Types of patients you found challenging in this rotation and what you learned about dealing with them

In this rotation, many patients with psychiatric conditions were not compliant with medications. They would be found with disorganized behavior by friends and family and got admitted to the inpatient unit. They would also usually have poor insight into their psychiatric condition and the need to take medication. In this situation, it was also very difficult to explain the importance of medication to patients with psychiatric conditions because they had difficulty understanding. They had lack of awareness of their illness. Some even heard voices telling them not to take medication. Patient’s failure to adhere to their medication as prescribed would also have a major impact on the course of illness and treatment outcomes. Long-acting medication would solve the problem of having to take medication every day. I learned that it was very important to understand the medications, such as their mechanism of action, metabolism, side effect, and indication in order to help patients to be more compliant with medication.

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc). 

My perspective had changed as a result of this rotation because I had found out that I was enjoying this rotation more than I had expected it to be. Although the psychiatric patients were poor historians, it was interesting to interview them. These patients were able to provide different kinds of stories. Clinicians actually had to sit down and observe in order to get to know their symptoms and come up with the diagnosis, without even touching the patients. Psychiatric patients were also acting in very disorganized and bizarre behaviors. The attendings, NPs, social workers, and nurses all know their roles in order to be in the team to provide quality care for the patients. They were also very friendly and willing to teach students.

How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

I have learned that the mental status exam for the psychiatric patients is like a stethoscope. We have to ask specific questions to know what they are thinking at the moment, as well as utilizing great observation skills. We have to observe their appearance, behavior, affect, speech, psychomotor activity etc. In the previous rotation, I have never observed patients in this much details. I learn that the time we put into observation can greatly help in the assessment of the patients. Paying attention to details will also be applicable in other rotations. When interviewing patients, I would not spend all my time writing notes in my book or typing in the computer. I would be paying more attention to the patient instead.

What do you want to improve on for the following rotations? What is your action plan to accomplish that?

In this rotation, I was not able to complete a lot of hands-on procedures on the psychiatric patients. Although I had done procedures in the previous rotations, I would still like to have the opportunity to practice more procedures. For the following rotations, I would like to be more proactive in order to get the chance for hands-on procedures. In addition, I would like to work on setting up treatment plan and know what to do with discharging patients. I would try to discuss with my preceptors and know how to improve my treatment plan for the patients.

Rotation 7 Psychiatry: Site Evaluation Summary

During the first site evaluation, each of the student presented a H&P. I presented a case on schizoaffective disorder. The site evaluator would give comments on places that we could improve for the final evaluation. We had learned that the mental status exam is very important for psychiatric patient presentation. For the final presentation, I presented another case on major depressive disorder and polysubstance abuse. We also talked about how the plan for the patient should had changed or improved. After that, I also presented an article on adjunctive therapy for schizophrenia. The site evaluator commented that I should had picked articles with a larger sample size for generalization. The article should also be done in the U.S because foreign health care system might be different compared to the one in the U.S. I agree with the site evaluator and I would make sure that my presenting articles in the future rotations would meet the requirements. The site evaluator also ensured that we are learning in our rotation site and that we feel safe in the site.

Link for article: article

Cannabidiol (CBD) as an Adjunctive Therapy in Schizophrenia: A Multicenter Randomized Controlled Trial.

Am J Psychiatry. 2018 Mar 1;175(3):225-231. doi: 10.1176/appi.ajp.2017.17030325. Epub 2017 Dec 15.

McGuire P¹, Robson P¹, Cubala WJ¹, Vasile D¹, Morrison PD¹, Barron R¹, Taylor A¹, Wright S¹.

 

Summary of the article:

The aim of the present study served to explore the safety and effectiveness of cannabidiol CBD as an adjunctive treatment in schizophrenia. In this randomized double-blind trial, 83 patients were randomized in a 1:1 ratio to receive CBD (1000mg/day) or placebo alongside their existing antipsychotic medication for 6 weeks. The researches examined the effects of CBD on positive and negative psychotic symptoms, cognitive performance, level of functioning, and the treating psychiatrist’s overall clinical impression. Participants were assessed before and after treatment using the Positive and Negative Syndrome Scale (PANSS), the Brief Assessment of Cognition in Schizophrenia (BACS), the Global Assessment of Functioning scale (GAF), and the improvement and severity scales of the Clinical Global Impressions Scale (CGI-I and CGI-S). The safety and tolerability of CBD were monitored through the assessment of adverse events, clinical laboratory tests, and vital signs.

Results:

• Compared with the placebo group, the CBD group had lower levels of positive psychotic symptoms (PANSS: treatment difference = -1.4, 95% CI= -2.5,-0.2)
• CBD group was more likely to have been rated as improved (CGI-I: treatment difference= -0.5, 95%CI=-0.8, -0.1) and as not severely unwell (CGI-S: treatment difference = -0.3, 95%CI=-0.5, 0.0) by the treating clinician.
• CBD group also showed greater improvements that fell short of statistical significance in cognitive performance (BACS: treatment difference=1.31, 95% CI=-0.10, 2.72) and in overall functioning (GAF: treatment difference=3.0, 95% CI=-0.4, 6.4)
• CBD was well tolerated, and the rate of adverse events were similar between the CBD and the placebo group.
• Findings suggest that CBD has beneficial effects in patients with schizophrenia. CBD acts in a way different from conventional antipsychotic medication, such as inhibition of fatty acid amide hydrolase, inhibition of adenosine reuptake, TRPV1 and 5HT1A receptor agonism. This may represent a new class of treatment for schizophrenia. This will require further research in larger-scale trials.

Rotation 7

Identification:

Patient’s name: SE

Age: 40

Gender: M

Race: Hispanic

Location: Elmhurst Hospital, Psychiatric inpatient unit

Informant: self, reliable

CC: “I am going to kill myself.”

HPI:

40 y.o Hispanic male with hx of substance abuse BIBEMS activated by his manager/ friend after patient texted “I quit, I am going to kill myself.” Patient admitted to taking 30 pills of Aleve and consumed ½ gallon of liquor with intent to kill himself. Patient stated that he was feeling “sad and depressed” on assessment, and “I’m tired of living. My whole life, I should not have been born”. He had been feeling depressed ever since his mother passed away for 2.5 years. Patient reported worsening depression and passive suicidal ideation after he lost his job at Con Ed which he worked for 15 years. Patient explained that after he lost his job, his friend hired him as a construction worker and he had been attending work intermittently.  Patient endorsed poor appetite, poor sleep and concentration as well as low energy, anhedonia and feelings of guilt for ruining his and his children’s lives. Patient got divorced about 1.5 years ago and was no longer able to see his children due to his hx of substance abuse. He also had on-going conflicts with his wife. Patient stated that he drinks ½ to 1 gallon of EtOH every other day, smokes marijuana every other day, and uses heroin once a week. Patient identified his family and friends as protective factors. Denies homicidal ideation, hallucinations, delusion, previous hx of suicidal attempts/ideations, prior hx of inpatient admission and rehab, past psychiatric medication, manic symptoms, and hx of aggression.  As per collateral obtained from patient’s friend, patient had been quiet and socially isolated after the death of his mother. Patient also had been making hopeless statements. But this time was the first time he texted and expressed suicidal ideation.

PMH:

Denies PMHx

Past Surgical History:

Denies past surgical hx

Medications:

Denies taking medications

Allergies:

NKDA

Family History:

Patient refused to elaborate on family history, but reported that his mother is an alcoholic.

Social History:

Patient lives alone, divorced with wife and was no longer able to see his children. He has 2 children (9 and 14 years old) but does not have custody. Currently unemployed. Patient started to drink EtOH at age 10, smoke marijuana every other day since 18 y.o, and use heroin once a week since 18 y.o.

ROS:

General: Patient denies recent weight loss or weight gain, generalized weakness, fatigue, fever, chill or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain, or last mammogram

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or stool guaiac test or colonoscopy

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain, hesitancy, dribbling or last prostate exam

Sexual history: Patient is not sexually active, denies impotence, or STD

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient reports depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities. Patient denies anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications.

Physical Examination (performed by ED)

General: 40-year-old male is alert and cooperative. He is well dressed and doesn’t appear to be acute distressed. Fair grooming, looks like his stated age of 40 years old. Well developed.

Vital Signs:

BP (seated): 136/94 left arm, sitting

HR: 75 BMP, regular

RR:  18, not labored

Temp: 98.5 F oral

O2 sat: 100% room air

Height: 5’5.75” weight:156lbs  BMI: 25.37

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution

Nails: No clubbing.

Head: Normocephalic, atraumatic.

Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears.

Nose: Symmetrical with no masses, lesions, deformities, or trauma.

Sinuses: not performed

Lips: Pink, dry, no cyanosis or lesions

Mucosa: not performed

Palate: not performed

Teeth: not performed

Gingivae: not performed

Tongue: not performed

Oropharynx: not performed

Neck: No masses, lesions or scars. Trachea midline.

Thyroid: Nontender, no palpable masses, no thyromegaly, no bruits

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. No wheezing, crackles, rales.

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR. No JVD.

Abdomen: Flat, symmetrical, no scars, striae. Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness.

Male genitalia and hernia: not performed

Anus, rectum, and prostate: not performed

Rectal: not performed

Peripheral vascular: The extremities are normal in color, size and temperature. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted

Neurological

Mental status exam:

General:

Appearance: Pt was medium build, dressed in a hospital gown and fairly groomed. He was sitting comfortably in a chair. Appeared like his stated age.

Behavior and psychomotor activity: Patient was calm and cooperative, moderate psychomotor retardation.

Attitude: Patient was cooperative and willing to answer questions. He established rapport in about 3-5 minutes.

Sensorium and cognition:

Alertness and consciousness: Patient remained alert and conscious throughout the interview.

Orientation: Patient was oriented to the time of day, the place of the exam, and the date.

Capacity to read and write: Patient had fair reading and writing capacity.

Abstract thinking: Patient did not use English metaphor to explain things, but was still able to clarify his thoughts. Patient was able to do simple calculations to determine his children’s age and date. His ability to use deductive reasoning was fair.

Memory: Patient’s remote and recent memory were normal.

Fund of information and knowledge: Patient’s intellectual performance was consistent with his educational level.

Mood and affect:

Mood: sad and depressed

Affect: blunted, constricted and depressed

Appropriateness: Patient’s mood and affect were consistent with the topics he discussed. He did not exhibit labile motions, angry outbursts, or uncontrollable crying.

Motor:

Speech: Patient was speaking slowly and softly.

Eye contact: Patient was trying to avoid eye contact.

Body movement: Patient had no extremity tremors or facial tics. His body movements were decreased and slow. Gait is normal.

Reasoning and control:

Impulse control: Patient has fair impulse control. He expressed suicidal, but not homicidal urge.

Judgement: Patient had no paranoia, bizarre delusions, auditory or visual hallucinations. Patient has goal-direct, linear and logical thought process.

Insight: Patient had fair insight into his psychiatric condition and the need for medications.

Cranial nerve: not performed

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Gait normal with no ataxia.

Sensory: not performed

Reflexes: not performed

Musculoskeletal System/Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Labs:

CBC: wnl

CMP: total protein 5.9 dec, AST 69 elevated, ALT 67 elevated

TSH: wnl

T4 free, T3: wnl

Acetaminophen level: <5

Salicylate: 0.3 dec

Blood alcohol level: 265 elevated

Lipid Panel: cholesterol 266 elevated

Syphilis: negative

Quan TB: negative

Urine drug screen: not collected

Assessment:

40 y.o Hispanic male with hx of substance abuse BIBEMS for suicidal ideations. Presentation is most consistent with major depressive disorder and polysubstance abuse.

Differential Diagnosis:

1. Major depressive disorder: Patient had persistent feelings of sadness, loss of interest in usual activities, guilt, changes in sleep, appetite, and concentration. Patient also had suicidal ideations.
2. Substance-induced depression: Patient had a history of substance abuse. Patient admitted to majriruana use every other day and heroin once a week. But urine drug screen was unable to collect from the patient.
3. Adjustment disorder: Patient reported that his mother passed away 2.5 years ago and he had been depressed ever since. Patient also lost his job at which he had worked for 15 years. This is less likely because it usually starts within 3 months of a stressful event and lasts no longer than 6 months.
4. Persistent depressive disorder: Patient had feelings of sadness, loss of interest in usual activities, guilt, changes in sleep, appetite, and concentration. Patient also had suicidal ideations. This is less likely because patient was never symptom-free in the 2-year period.
5. Bipolar disorder: Patient could be in the depression phase of bipolar disorder. But this is less likely as patient did not experienced any manic or hypomanic symptoms.

Plan:

1. EtOH abuse:

• Continue to monitor for s/s of EtOH withdrawal
• v/s q4h
• Thiamine 100mg po daily
• Folic acid 1 mg po daily
• Librium 25-50 mg po q6h prn
• Multivitamin 1 tab PO daily

1. Depression; high risk

• Inpatient admission for observation and stabilization
• Placed on 1:1 for suicidality
• Vital sign q4h
• Ativan PO 1mg q6h prn
• Mirtazapine 15mg PO nightly

Typhon Psych

Rotation 6 OBGYN reflection

Types of patients you found challenging in this rotation and what you learned about dealing with them

I found OB patients to be challenging in this rotation. Their management can be completely different based on their gestational age. They don’t just present for delivery, but also prenatal care and routine checkup during pregnancy. There are also different tests that needed to be order based on trimester. I found that there are no short cuts to learn this. I have learned that the more OB patients I get to see in clinic, in labor and delivery, and during postpartum rounds, the more I will learn to manage based on different stages of the pregnancy. There are also a lot of “numbers” to remember for OBGYN, such as the gestational week for ordering a certain test, the gestational week for different trimester, the blood pressure cut off for confirming different severity of pre-eclampsia, etc. Seeing more OB patients in this rotation is helpful in learning the management based on different gestational age.

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc). 

My perspective on diversity has changed as a result of this rotation. I have noticed a lot of Spanish-speaking patients in the hospital where I am doing my rotation. Personally, I do not speak Spanish and I would have to call the interpreter for translation every time I have to interview a Spanish speaking patient. Even though phone interpreter is very convenient and we can have access to it anywhere in the hospital, bad connections can often prevent the interpreters from listening the complete message and they are limited to only what they hear. After seeing a lot of Spanish speaking patients, they motivate me to learn to speak Spanish. I think taking a medical Spanish course in the near future will be beneficial in the hope of serving a larger and diverse community.

How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

In this rotation, I have a lot of opportunity to perform pelvic exam including pap smear and vaginal cultural swab. I think it is important to have the proper skill of performing a female genital exam because gyn complaints are very common. Doing a proper gyn exam will aid in the guidance of diagnosis and treatment. Doing pap smear is helpful in screening cervical cancer by identifying abnormal cervical cells, which will lead to early treatment before symptoms even occur. Additionally, endocervical culture will help to identify STDs before it gets complicated into pelvic inflammatory disease and infertility in women. I have also had chances to learn and perform pelvic and transvaginal ultrasounds. These tools are essential in diagnosing life threatening cases like ectopic pregnancy, or to provide care for pregnant patients.

What do you want to improve on for the following rotations? What is your action plan to accomplish that?

In the future rotations, I would like to continue seeking opportunities to complete more hands-on procedures. In order to do this, it will be important for me to stay proactive in this rotation. I will also want to be more prepared prior to the start of the rotation. I will start reading and reviewing the topics before the start of the rotation. This will help me to better adjust and familiarize with different disease.

Rotation 6 OBGYN: Site Evaluation Summary

During the site evaluations, I presented a case on PCOS and infertility. Then I also presented an article related to PCOS. The article concluded that PCOS was associated with non-alcoholic fatty liver disease. I chose to present on PCOS because it was common in women. Untreated PCOS overtime could lead to serious health complications such as diabetes and cancers. After I presented, my site evaluator also went over this topics with me. We discussed about the pathophysiology, clinical manifestation, diagnosis, as well as different management of PCOS. The review was extremely helpful. In addition, I presented my pharm cards. My site evaluator also went over my procedure log book to ensure that I was getting the opportunity to complete different procedures. We also talked about site related questions. She made sure that I was seeing an adequate number and variety of patients every day, that I was having bedside teaching and access to resources.

Article PCOS

Non‐alcoholic fatty liver disease in women with polycystic ovary syndrome: systematic review and meta‐analysis

1. L. Rocha1 · L. C. Faria2 · T. C. M. Guimarães2 · G. V. Moreira1 · A. L. Cândido2 · C. A. Couto2 · F. M. Reis

J Endocrinol Invest 2017

Overview of PCOS:

• It is endocrine syndrome characterized by triad of amenorrhea, obesity, and hirsutism. The main stay of treatment is combination OCPs.

Article Summary:

• The purpose of the study is to assess the association of PCOS with non-alcoholic fatty liver disease. Like PCOS, NAFLD is associated with obesity, DM, insulin resistance, and metabolic syndrome. PCOS women have increased risk of NAFLD, but it is debatable which features of PCOS affect the NAFLD risk.
• Method: 17 studies published between 2007 and 2017 that included 2,734 PCOS patients and 2561 controls of similar age and BMI.
• Results: PCOS patients have increased prevalence of NAFLD (odds ratio 2.54, 95% confidence interval 2.19-2.95). PCOS women with hyperandrogenism have a higher prevalence of NAFLD compared to women with PCOS without hyperandrogenism. The presence of NAFLD is also associated with high serum total testosterone, in addition to obesity and insulin resistance.
• It is important to know about PCOS because it is common in reproductive women. It can lead to health complication if PCOS is untreated. Besides fertility problems, complications include risk for developing insulin resistance, diabetes, abnormal cholesterol/triglyceride level, heart disease, stroke, obesity, and endometrial cancer.

Rotation 6

Identification:

Patient’s name: RM

Age: 25

Gender: Female

Race: Hispanic

Location: Woodhull Hospital, OBGYN clinic

Date: 7/17/19

Informant: self, reliable

CC: “Irregular menses since menarche”

HPI:

25 y/o F G0P0, LMP 2/1/19, with PMHx of constipation presents to the Women’s health clinic with irregular menstruation since menarche. States that she has approximately 3-4 x menstruations in one year, each time last about 3-4 days, medium flow without clots. She has not had a period for more than 5 months. Pt is currently sexually active with one partner, male only, and using condom inconsistently. Further states that she has gained 40-50 lbs in the past 5 months and has difficulty losing weight. Denies hx of STDs, abnormal vaginal discharge, abnormal Pap results, dyspareunia, pelvic pain, urinary symptoms, cold/hot intolerance/palpitation, hirsutism, galactorrhea, N/V, adult acne, facial hairs, significant headache or vision changes.

Differential Diagnosis:

Pregnancy- the first thing I want to rule out for amenorrhea for a woman in childbearing age. Pt is sexually active and using condoms inconsistently

Hypothyroidism- irregular menses and weight gain, hx of constipation.

PMH:

Constipation

Past Surgical History:

None

Medications:

None

Allergies:

NKDA

Family History:

Denies family hx of irregular menstruation, breast cancer, ovarian cancer, and colon cancer.

Social History:

Denies use of EtOH/cigarettes/illicit drugs. Denies exercising and healthy diet.

ROS:

General: Patient denies loss of appetite, generalized weakness, fatigue, fever, chill or night sweats. Admits to recent weight gain of 40-50 lbs in the past 5 months

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, rectal bleeding, blood in stool or stool guaiac test or colonoscopy. Admits to constipation.

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain

Menstrual and Obstetrical: Patient last normal period is 2/1/19, does not remember time of menarche, her menstrual cycle is irregular with medium flow without clots. Patient denies postcoital bleeding, dyspareunia, G0P0000. Last pap smear was 2 years ago, negative for malignancy.

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

Physical Examination:

General: 25 y.o obese female is alert and cooperative. She is well dressed and doesn’t appear to be distressed. Appears like her stated age.

Vital Signs:

BP (seated): 137/80

HR: 72 BMP, regular

RR:  14, not labored

Temp: 97.5 F oral

O2 sat: 100% room air

Height:5ft 1 weight: 257lbs  BMI: 48.6 obese

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution, no facial hair or chest hair

Nails: not performed

Head: not performed

Eyes: not performed

Ears: not performed

Nose: not performed

Sinuses: not performed

Lips: Pink, dry, no cyanosis or lesions

Mucosa: not performed

Palate: not performed

Teeth: not performed

Gingivae: not performed

Tongue: not performed

Oropharynx: not performed

Neck: No masses, lesions or scars. Trachea midline. Supple nontender to palpation.

Thyroid: Nontender, no palpable masses, no thyromegaly.

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR.

Breast: Normal contours, no nodules, mass, tenderness, nipple discharge or dimpling.

Abdomen: Flat, symmetrical, no scars, Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness.

Female genitalia: External – normal pubic hair pattern, no erythema, inflammation, ulcerations, lesions or discharge. Vaginal mucosa without inflammation, erythema or discharge. Cervix without lesions or discharge. No cervical motion tenderness. Uterus mobile, non-tender and of normal size, shape, and consistency. Adnexa without masses or tenderness

Rectal: not performed

Peripheral vascular: not performed

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve: not performed

Motor/Cerebellar: not performed

Sensory: not performed

Reflexes: not performed

Upper extremities and lower extremities musculoskeletal: Not performed

Imaging and lab works:

Transvaginal ultrasound: pending (patient needs to make an appointment for ultrasound)

Pelvic ultrasound: pending

DHEA sulfate: 152

LH: 11.1

FSH: 5.1

TSH: 1.2

Estrogen level: wnl

Lipid Panel: cholesterol 128, HDL 40, TG 90, LDL 70, cholesterol/HDL ratio 3.2

CMP: wnl

CBC: wnl

Hgb AlC: 6.3

Testesterone, free: 2.4

Testeterone, total: 39.7

Urine pregnancy test: negative

Prolactin: 17

Assessment:

25 y/o female presents with oligomenorrhea, weight gain, and elevated A1C, most likely secondary to PCOS.

Differential Diagnosis:

PCOS: oligomenorrhea, weight gain, and elevated A1C. Will need ultrasound to further assess.

Hypothyroidism- irregular menses and weight gain, hx of constipation. Less likely due to lab shows normal TSH.

Hyperprolactinemia or other hormonal abnormalities- irregular menses, weight gain. Less likely due to normal level of prolactin, normal FH, normal LH, normal testosterone.

Premature ovarian failure: irregular menses, but less likely due to normal levels of hormones

Anatomical problems – irregular menses, but will need ultrasound to further assess.

Plan:

Nutritionist referral

Life style modification – with 10% weight loss over the next 6 months

Advise patient to keep her ultrasound appointment

F/U in 1 month after ultrasound result come back

Patient Education:

Irregular menses can be due to many reasons. We will do lab work to find out what is going on with your menstruation. PCOS is one of the common cause for irregular menses and monthly ovulation is not occurring. It occurs in about 10% of women. Most women with PCOS are obese and insulin resistance. Although PCOS is not completely reversible, there are a number of treatment that can reduce or minimize bothersome symptoms.  Most women with PCOS are able to lead a normal like without significant complications. We will set you up to talk to a nutritionist for diet modification. You are also encouraged to exercise and set up a goal with 10% weight loss over the next 6 months. Make sure that you keep your ultrasound appointment so that we can better help you with your symptoms. You will need to come back in 1 month for a follow up appointment. We will see how you have changed. Oral contraceptives can be used for regulating your menses, but weight loss is one of the most effective approaches for managing insulin abnormalities, irregular menstrual periods, and other symptoms of PCOS.

HP1