Assignment 5: Type 1 Diabetes mellitus

Patient name: D, V Age: 40 Gender: Female

Chief Complaint:” I have been without menses for 2 months”

HPI: Patient 40 years old female, Hispanic, comes to visit for gynecologic examination, complaining of amenorrhea for 2 months, reports irregular periods before.

Past Medical Hx:

Essential (primary) hypertension I10

Obesity, unspecified E66.9

Hyperlipidemia E78.1

Type 1 Diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.319

Pap smear

Date: 11/17/2018; Notes: HPV negative but reactive cellular changes and/or repair are present, the predominance of coccobacilli consistent with a shift in vaginal flora is present

Date: 11/23/2016; Notes: Normal

Notes: Normal 2008 Negative for Cancer of the ovaries; Asthma; Cancer of the breast; Cancer of the lung; Diabetes; Heart failure, systolic; Heart disease (CAD); Cancer of the colon; Heart failure, diastolic.

Menstrual History

Menstrual information

Notes: Irregular

Pregnancy History

Past pregnancy

Notes: G2 P2 A0 L2

Surgical History

Cesarean section

Social History

Sexually active

Employed

Children

Married

Never smoked

Negative for: Exercise; Past drug use; Alcohol use

Family Hx:

Father: Diabetes mellitus

Mother: Hypertension,

Grandparents: Diabetes mellitus

Allergies: No Know Allergies

Current Medication:

Lisinopril 10 mg tab PO daily.

Glargine 40 units at bedtime

Atorvastatin 80 mg tab PO at bedtime daily

Review of systems

General/Constitutional

Patient t Reports: Amenorrhea for 2 months, she denies chills and night sweats. She also denies weight loss and weight gain or fever.

HEENT

Eyes: Denies swellings, itchiness, blurry vision, discharges. The patient wears glasses.

Head: Denies (pain, vertigo, tinnitus, hoarseness, dysphagia, cough, throat pain, hearing problems, trauma, lump).

Systemic symptoms: Denies (fever, chills). No recently weight loss.

Neurological: Denies sleeping problems, nausea, vomiting, vertigo, weakness, gait change, dizziness, or headache.

Respiratory: Denies cough, shortness of breath, chest pain, cyanosis.

Cardiovascular: Last EKG (atrial fibrillation). The patient denies chest pain, dizziness, SOB, weakness, fatigue, bilateral lower extremity swelling.

Gastrointestinal: Denies abdominal pain, distention, anorexia, diarrheas, nauseas, vomiting, flatulence.

Genitourinary: Pt Reports: Amenorrhea for 2 month, She denies increased urinary frequency, blood in the urine, and nocturia.

Endocrinology: Denies: Excessive appetite; Excessive sweating; Excessive thirst; Excessive urination; Heat/cold intolerance; Hair loss; Excess hair growth

Musculoskeletal: Denies arthralgia, myalgia, or pain to the movement of the joints or muscles cramp.

Integumentary: Denies discomfort and itching in her vagina, denies swollen.

Pt Denies: Skin lump/mass; Mole changes; Performs monthly self-breast exam; Breast lump/mass; Breast pain; Nipple discharge; Stretch marks; Varicose veins; Phlebitis

Neurological: Pt denies Headaches Pt Denies Numbness/tingling; Seizures; Tremors; Difficulty walking; Localized weakness Psychiatric. Pt Denies: Anxiety; Depression; Frequent crying; Nervousness; Hallucinations; Memory loss; Sleep problems; Suicidal thoughts

Hematologic/Lymphatic Pt Denies: Easy bleeding or bruising; Anemia; Swollen glands Allergic/Immunologic

Physical examination

Weight: 172 lbs Temp 98.1 F BP: 132/86 Height 5’2” Pulse:82 Resp: 20

General: The patient is alert and oriented, able to provide accurate information, good eye contact during the interview, cooperative. The patient states a good understanding of the conversation. The patient seems slightly distressed

HEEET Head: Normocephalic, atraumatic, symmetric, no visible or palpable masses, depressions, or scaring. Good hair distribution, good hygiene. No bleeding, no papules, no vesicles.

Neck: Trachea in the midline, No neck veins distention. No posterior cervical adenopathy. No carotid bruits and no goiter.

Ears: TMs (Pale, gray, translucent appearance, Cone of light and bony landmarks visible) & mobile, hearing intact. Ear canals clear without inflammation or redness.

Nose: Smell sense intact, No external or internal lesions observed. No exudate or secretion. No observed septum deviation.

Eyes: Visual acuity intact 20/20 with corrective glasses, Eyes symmetric, no blepharitis, no redness clear conjunctiva, no ocular discharge bilaterally. PERRLA

Throat: Gap reflex present, uvula in the midline, Good hygiene, No lesions in soft tissues, no gingival inflammation, no bleeding. Tonsils 2+

Respiratory: Chest symmetric, Tactile fremitus present. thoracic expansion symmetric. No wheezing or crackles sounds.

Breast: No overlying skin changes; No dimpling; No nipple retraction; No masses or lumps; Right breast no palpable masses or lumps; Left breast no palpable masses or lumps; No tenderness; No regional lymphadenopathy

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Additional comments: US-guided biopsy right breast, showing fibroadenoma, no malignancy was seen. Diagnostic mammogram and ultrasound in 1 year are recommended (August 2021)

Skin: Warm to touch, no hyperthermia, Inguinal intertrigo Assignment 5: Type 1 Diabetes mellitus

Cardiovascular: HR regular. No murmur, no thrill, no rubs, No swollen leg. All pulse palpable, no sign of DVT or PAD.

Abdomen: Flat, no tender no distended, No scar visible on inspections, soft on palpation. Liver palpable no splenomegaly, no masses, no pain with palpation. Bowel sound present in all quadrant. The patient denies Costovertebral angle tenderness.

Genitourinary: No erythema, masses, or lesions detected on the external genitalia. The vaginal mucosa is pink. No blood detected on the stool, which is brown. No inguinal adenopathy or adnexal masses noted. No rectovaginal masses detected. Vulva,Vagina,Cervix (Normal appearance); By TV sonogram (Uterus normal size/shape with normal ovaries)

Lymphatic: No visible or palpable adenopathy.

Extremities: Full range of motion in 4 extremities, Pulses present and symmetric. No swelling, no deformities

Neurological: All cranial nerves intact. No weakness, no vertigo, or dizziness. Adequate sensation in 4 extremities. Reflexes are +2

Assessment and Plan

Diagnosis:

Amenorrhea, unspecified N91. Amenorrhea is the absence of menstruation. Secondary amenorrhea occurs when you’ve had at least one menstrual period and you stop menstruating for three months or longer. Secondary amenorrhea is different from primary amenorrhea. It usually occurs if you haven’t had your first menstrual period by age 16.A variety of factors can contribute to this condition, including birth control use, certain medications that treat cancer, psychosis, or schizophrenia, hormone shots, medical conditions such as hypothyroidism, being overweight or underweight

Differential Diagnosis:

Hypothyroidism E03.9: Other clinical signs of thyroid disease are usually noted before amenorrhea presents. Mild hypothyroidism is more often associated with hypermenorrhea or oligomenorrhea than with amenorrhea. Treatment of hypothyroidism should restore menses, but this may take several months.

HYPERGONADOTROPIC HYPOGONADISM E23.0: Ovarian failure can cause menopause or can occur prematurely. On average, menopause occurs at 50 years of age and is caused by ovarian follicle depletion. Premature ovarian failure is characterized by amenorrhea, hypoestrogenism, and increased gonadotropin levels occurring before 40 years of age and is not always irreversible (0.1 percent of women are affected by 30 years of age and one percent by 40 years of age). Approximately 50 percent of women with premature ovarian failure have intermittent ovarian functioning with a 5 to 10 percent chance of achieving natural conception

Polycystic ovary syndrome (PCOS) E 28.2: is a hormonal disorder common among women of reproductive age. Women with PCOS may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels. The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs.

The exact cause of PCOS is unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complications such as type 2 diabetes and heart disease.

PLAN

Further Testing:

Pregnancy test. This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy.

Thyroid function test. Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly.

Ovary function test. Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.

Prolactin test. Low levels of the hormone prolactin may be a sign of a pituitary gland tumor.

Transvaginal ultrasound.

Medication: Treatment depends on the underlying cause of your amenorrhea. In some cases, contraceptive pills or other hormone therapies can restart your menstrual cycles. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a tumor or structural blockage is causing the problem, surgery may be necessary.

Education: Some lifestyle factors such as too much exercise or too little food can cause amenorrhea, so strive for balance in work, recreation, and rest. Assess areas of stress and conflict in your life. If you cannot decrease stress on your own, ask for help from family, friends or your doctor.

Be aware of changes in your menstrual cycle and check with your doctor if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts and any troublesome symptoms you experience.

Return to office: The patient should return to the clinic immediately if the condition worsens and symptoms persist. Follow-up should be done in two weeks if the condition does not worsen.

References

DeCherney AH, et al. Current Diagnosis & Treatment Obstetrics & Gynecology.11th ed. New York, N.Y.: The McGraw-Hill Companies; 2013. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=788. Accessed Jan. 21, 2014. Assignment 5: Type 1 Diabetes mellitus

Klein DA, et al. Amenorrhea: An approach to diagnosis and management. American Family Physician. 2013;87:781.

Goldman L, et al. Goldman’s Cecil Medicine. 24th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. http://www.clinicalkey.com. Accessed Jan. 20, 2014.