For the past 2 weeks, she was experiencing abdominal pain that make her woke up at night, but it is relieved by food and antacids. She was diagnosed with Grave’s disease 3 months ago with symptoms of hyperthyroidism and tachycardia. She also has chronic renal dysfunction due to polycystic kidney disease. Moreover, she has IBS with complaints of diarrhea and constipation, with increasing episode over past 2 months. She was also diagnosed with iron deficiency anemia. CJ was married and had 2 children. She smoke ½ pack per day and drinks 2 glasses of wine per day with dinner and coffee 2-6 cups per day. Medication: PTU 200 mg PO q6h Magnesium hydroxide/Al hydroxide Susp 15mL PO PRN Propranolol 20 mg PO qid. Allergies: NKA Physical Examination: Gen: Well developed, thin female in mild distress VS: BP 140/88, HR 84, RR 18, T 37oC. Wt 55 kg, Ht 165cm HEENT: Small symmetric goiter, much smaller than previous clinic visit Coronary: Normal S1 and S2, no murmurs, rubs, or gallops Chest: WNL Abdomen: Intermittent, crampy, lower abdominal pain relieved by passage of flatus; point tenderness between the xiphoid and umbilicus Genitourinary: WNL Ext: Pruritic pretibial myxedema Neuro: WNL Laboratory Examination Results: (SI UNIT) Na 128 mmol/L Fe 9.8 umol/L Plts 120 x 109/L K 4.8 mmol/L Mg 1.35 mmol/L Glu 4.7 mmol/L Cl 102 mmol/L MCV 68 um3 Ca 2.1 mmol/L HCO3 20 mmol/L AST 0.42 ukat/L Uric Acid 535 umol/L BUN 28.6 mmol/L ALT 0.45 ukat/L T Bili 15.4 umol/L Cr 283 (3.2) PO4 1.6 mmol/L TT4 100 nmol/L Hct 0.29 Alb 35 g/L RT3U 0.3 nmol/L Hgb 100 mmol/L LDH 1.1 ukat/L FT4I 34 pmol/L LKcs 5 x 109 cells/L Alk Phos 1.1 ukat/L TSH 5 mIU/L Stool guaiac test: Guaiac-positive stool ¹1Differential test: WNL Urinalysis: Hematuria, proteinuria Chest radiography: WNL ECG: WNL Endoscopy: Two small duodenal ulcers Peripheral blood smear: Microcytic anemia Prioritized problem list: This list should be complete for all ACTIVE problems for this patient and numerically prioritized according to severity. Health Care Problems Priorit
-
For the past 2 weeks, she was experiencing abdominal pain that make her woke up at night, but it is relieved by food and antacids.
She was diagnosed with Grave’s disease 3 months ago with symptoms of hyperthyroidism and tachycardia. She also has chronic renal dysfunction due to polycystic kidney disease. Moreover, she has IBS with complaints of diarrhea and constipation, with increasing episode over past 2 months. She was also diagnosed with iron deficiency anemia.
CJ was married and had 2 children. She smoke ½ pack per day and drinks 2 glasses of wine per day with dinner and coffee 2-6 cups per day.
Medication:
PTU 200 mg PO q6h
Magnesium hydroxide/Al hydroxide Susp 15mL PO PRN
Propranolol 20 mg PO qid.
Allergies: NKA
Physical Examination:
Gen: Well developed, thin female in mild distress
VS: BP 140/88, HR 84, RR 18, T 37oC. Wt 55 kg, Ht 165cm
HEENT: Small symmetric goiter, much smaller than previous clinic visit
Coronary: Normal S1 and S2, no murmurs, rubs, or gallops
Chest: WNL
Abdomen: Intermittent, crampy, lower abdominal pain relieved by passage of flatus; point tenderness between the xiphoid and umbilicus
Genitourinary: WNL
Ext: Pruritic pretibial myxedema
Neuro: WNL
Laboratory Examination Results: (SI UNIT)
Na
128 mmol/L
Fe
9.8 umol/L
Plts
120 x 109/L
K
4.8 mmol/L
Mg
1.35 mmol/L
Glu
4.7 mmol/L
Cl
102 mmol/L
MCV
68 um3
Ca
2.1 mmol/L
HCO3
20 mmol/L
AST
0.42 ukat/L
Uric Acid
535 umol/L
BUN
28.6 mmol/L
ALT
0.45 ukat/L
T Bili
15.4 umol/L
Cr
283 (3.2)
PO4
1.6 mmol/L
TT4
100 nmol/L
Hct
0.29
Alb
35 g/L
RT3U
0.3 nmol/L
Hgb
100 mmol/L
LDH
1.1 ukat/L
FT4I
34 pmol/L
LKcs
5 x 109 cells/L
Alk Phos
1.1 ukat/L
TSH
5 mIU/L
Stool guaiac test: Guaiac-positive stool
¹1Differential test: WNL
Urinalysis: Hematuria, proteinuria
Chest radiography: WNL
ECG: WNL
Endoscopy: Two small duodenal ulcers
Peripheral blood smear: Microcytic anemia
Prioritized problem list: This list should be complete for all ACTIVE problems for this patient and numerically prioritized according to severity.
|
Health Care Problems |
Priority |
Step by step
Solved in 2 steps
