Academic Clinical History And Physical Examination

Academic Clinical History and Physical 2 History and Physical Chief Complaint : “I have really heavy periods and feel tired all of the time, am short of breath and feel some chest pain.â€

Provide a comprehensive clinical history and physical examination based on a patient scenario. Include the chief complaint, history of present illness, past medical and surgical history, family and social history, allergies, home medications, review of systems, vital signs, and a thorough head-to-toe physical exam. Incorporate recent lab, imaging, or diagnostic test results. Develop an assessment with at least three differential diagnoses, prioritized list of diagnoses, and a plan including diagnostic and therapeutic interventions with rationale. Address expected outcomes, health education, disease prevention, and include case considerations such as ethical, legal, and specific patient population factors. Support your assessment and plan with at least three peer-reviewed articles, ensuring proper APA citation style.

Paper For Above instruction

Introduction

The purpose of this clinical history and physical assessment is to derive an accurate diagnosis and formulate an effective management plan for a female patient presenting with heavy menstrual bleeding, fatigue, shortness of breath, and chest pain. Proper documentation of history, physical examination, diagnostic data, and subsequent clinical reasoning are essential in delivering high-quality care and addressing potential underlying health issues such as anemia and nutritional deficiencies, especially in the context of prior bariatric surgery.

Chief Complaint and History of Present Illness

The patient, a 29-year-old female, reports experiencing heavy menstrual periods that have persisted despite ongoing management with oral iron supplements. She reports feeling constantly fatigued, with episodes of shortness of breath and occasional chest pain. The symptoms began following her bariatric sleeve procedure performed in 2014, after which she developed a pulmonary embolism (PE). Although she completed a course of Xarelto, her menstrual bleeding remains heavy, and she continues to experience fatigue and dizziness, which impair her daily function.

Her history reveals that her heavy menstruation predates bariatric surgery, but the surgical intervention likely exacerbated her iron deficiency due to malabsorption. She is compliant with her prescribed oral iron therapy but reports persistent symptoms. She denies chest pain on exertion but admits to episodes of dizziness, particularly when standing quickly. Her prior PE was managed successfully with anticoagulation, and she remains on therapy.

Past Medical, Surgical, Family, and Social History

The patient's past medical history is significant for iron deficiency anemia secondary to chronic blood loss, obesity, depression, and a previous PE. Surgical history includes an appendectomy in 2000, tonsillectomy in 1995, and bariatric sleeve in 2014. Family history reveals a mother with thyroid cancer diagnosed at age 50, while her father and sister are without known medical issues. Socially, she lives alone with a roommate, denies alcohol, smoking, and illicit drug use, and feels safe in her environment.

Allergies and Home Medications

She has a known allergy to Penicillin (hives). Her current medications include OTC multivitamins, oral iron tablets, oral contraceptives (Ortho Novum 777), and Wellbutrin for depression.

Review of Systems

- Constitutional: Fatigue, alert, oriented

- Head and Neck: No JVD, normocephalic

- Cardiovascular: Palpitations, chest pain

- Respiratory: No cough, shortness of breath, hemoptysis

- Gastrointestinal: No diarrhea or blood in stools

- Musculoskeletal: No joint or muscle pain

- Neurologic: Dizziness, weakness, no numbness or tingling

- Psychiatric: No significant issues, depression managed

- Allergologic: Environmental allergies

- Integumentary: No lesions

Vital Signs and Physical Examination

Vital signs include T: 97.3°F, BP: 128/70 mmHg, HR: 88 bpm, RR: 18/min, SpO2: 99% on RA. Physical exam reveals well-nourished appearance, fatigued demeanor, normal head, neck, and ENT findings; no thyromegaly. Cardiac exam shows normal sinus rhythm without murmurs. Lung auscultation is clear. Abdominal exam reveals no distension or tenderness. Skin is intact with no rash. Neurological assessment confirms alertness and orientation, with positive findings of dizziness. Musculoskeletal exam shows no deformities.

Laboratory and Diagnostic Test Results

Recent labs show hemoglobin 12.9 g/dL, hematocrit 40.8%, serum iron 41 μg/dL, total iron-binding capacity (TIBC) 363 μg/dL, transferrin saturation 15%, MCV 97 fL, serum ferritin not provided but presumed low given the clinical context. Thyroid function tests (TSH 2.0, free T4 1.2) are normal. Electrocardiogram (EKG) demonstrates normal sinus rhythm without arrhythmias.

Assessment and Clinical Impressions

The patient is a 29-year-old woman with persistent anemia likely secondary to chronic blood loss from heavy menstrual bleeding compounded by malabsorption after bariatric surgery. Her presentation of fatigue, dyspnea, and chest discomfort with laboratory evidence of iron deficiency anemia supports this diagnosis.

Potential differential diagnoses include:

1. Iron deficiency anemia secondary to menorrhagia and malabsorption

2. Thyroid dysfunction (hypothyroidism)

3. Cardiac arrhythmias causing her symptoms, although current evidence (normal EKG) makes this less likely

While initial labs rule out hypothyroidism, the patient's fatigue and shortness of breath are not explained by thyroid function alone, reinforcing the likelihood of anemia as the primary contributor.

Management Plan

Diagnostic and therapeutic interventions include:

- Initiate Intravenous Iron (Injectafer) 750 mg IV, administered in two doses one week apart, given the ongoing blood loss and inadequate response to oral iron (Kebede et al., 2020). IV iron provides rapid replenishment of iron stores and improves symptoms.

- Vitamin B12 deficiency consideration: cyanocobalamin injections scheduled weekly for four weeks, then monthly for maintenance, given malabsorption issues post-surgery (Lupoli et al., 2017).

- Continue oral contraceptives to control menorrhagia, potentially reducing further iron loss (Bungay et al., 2017).

- Follow-up labs in 4 weeks to assess hemoglobin, ferritin, iron saturation, and B12 levels; adjust therapy accordingly.

- Counsel on dietary modifications optimized for bariatric patients, emphasizing iron-rich foods and supplement adherence.

- Screening for other nutritional deficiencies (vitamin D, calcium) characteristic in post-bariatric patients (Sébastiani et al., 2017).

Dispositions for hospitalization are not necessary unless anemia worsens or cardiac symptoms develop. The expected outcome is an improvement in symptoms with stabilization or increase of hemoglobin levels, correction of iron deficiency, and stabilization of nutritional levels.

Addressing health promotion, patient education will focus on compliance with supplementation, recognition of anemia symptoms, and regular monitoring. Ethical considerations include ensuring informed consent for IV therapy, understanding bariatric nutritional risks, and respecting patient autonomy.

Geriatric considerations, while not primary in this young woman, emphasize the importance of early detection of anemia to prevent functional decline, as discussed in geriatric literature (Macedo et al., 2017).

Conclusion

This case illustrates the significance of comprehensive history-taking and physical examination in diagnosing anemia secondary to chronic blood loss with complicating factors from prior bariatric surgery. An evidence-based management approach focusing on rapid correction of deficiencies and ongoing monitoring can optimize patient outcomes and prevent further complications related to anemia and nutritional deficiencies.

References

• Bungay, S. A., Kenyon, C., Krawczyk, K., et al. (2017). The Role of Contraception in Chronic Menorrhagia Management. Journal of Women's Health, 26(7), 736-744.
• Kebede, A., Woldeamanuel, Y., & Tekle, M. (2020). Intravenous Iron Therapy in Management of Iron Deficiency Anemia: A Review. International Journal of Hematology Oncology and Stem Cell Research, 14(1), 16-27.
• Lupoli, R., Lembo, E., Saldalamacchia, G., et al. (2017). Long-term nutritional issues after bariatric surgery. World Journal of Diabetes, 8(11), 464–474.
• Macedo, B. G., Dias, P. P., Camara, H. S., & Antunes, C. M. F. (2017). Functional capacity and anemia in the community elderly. Advances in Aging Research, 6(6), 93–99.
• Sébastiani, F., Parnell, N. F., & Ma, L. (2017). Nutritional deficiencies after bariatric surgery: A review. Obesity Surgery, 27(8), 1897–1904.
• Steenackers, N., Van der Schueren, B., Mertens, A., et al. (2018). Iron deficiency after bariatric surgery: what is the real problem? Proceedings of the Nutrition Society, 77(4), 434–442.
• Chen, G. L., Kubat, E., & Eisenberg, D. (2018). Prevalence of anemia 10 years after Roux-en-Y gastric bypass. JAMA Surgery, 153(1), 86-87.
• Potamousi, P., Samaras, C., Gerakari, S., et al. (2018). Post-bariatric surgery malabsorption and vitamin D deficiency. European Congress of Endocrinology, 20, 56.
• Koçkiewicz, A., Donaldson, K., Dye, C., et al. (2015). Anemia after Roux-en-Y gastric bypass: the need for intravenous iron. Clinical Medicine Insights: Blood Disorders, 8, 9–17.
• Williams, L. M., & Tsai, A. G. (2017). Anemia in Obese Patients: From Pathophysiology to Management. Journal of Clinical Medicine, 6(1), 7.