Caroline Casey SOAP Ihuman Case Study

Case study samples that are based on Ihuman cases of patients help to come up and develop diagnosis and reviews on these sample subjects. They help to provide an overall outlook into the health complaints of patients and diagnosis conducted.

Below is an ihuman case study of Caroline Casey

Date of encounter: 7/3/2020 

Patient Name or initials: Caroline Casey (CC)

Informant: Patient

Chief Complaint (CC): Patient is here to discuss contraception options and “getting back to normal self” due to recent fatigue.

History of present illness (HPI):

Patient is a 25 y.o. African American female G1P1001 with history of a DVT who presents to office to discuss contraception and “getting back to normal self”. Patient recently gave birth to a son 9 months ago and felt “good” first two months after delivery then began to develop fatigue. The fatigue has been increasing and does not improve with sleep. Patient is also experiencing heavier periods with dime sized clots, soaking through4-5 tampons a day and requiring a backup pad. Patient describes her tiredness as moderate and getting worse.

Allergies: Latex (rash)

Food allergies: Strawberries, Kiwis (trouble breathing)

Medications: Tylenol PRN

Past History: DVT

Family History: Unknown, patient was an orphan and denies knowledge about family history

Personal and Social History:

Denies alcohol and recreational drug use.

Pertinent Review of systems (ROS):

List pertinent +. If positive, expand upon with the 7 attributes in the HPI.

General: The patient describes an overall good state of health but complains of fatigue. Denies fever, chills, weight loss or weight gain.

Skin: Warm and dry, denies any rash skin changes, or lesions.

HEENT: Denies headache, changes in vision or throat soreness

Neck: pain, limitation of motion, lumps or swelling, enlarged or tender nodes

Breast: pain, lump, nipple discharge, rash

Respiratory: Denies shortness of breath at rest, denies cough. Complains of some dyspnea on exertion

CV: Denies chest pain, palpitations.

GI: Normal bowel movements. Denies nausea/vomiting.

GU: Denies issues with urination, hematuria

Peripheral Vascular: Denies swelling or leg pain.

Endocrine: Denies weight loss or gain, cold intolerance, or skin changes

Neuro: LOC, seizure activity, developmental delays, nervousness, dizziness, headache, changes in memory, changes in mood

MS: Denies weakness, denies musculoskeletal issues

Sexual Health: Uses a male condom with partner

Female Genital System: Age 12 at menarche, period every 28 days lasts, recently had very heavy periods first 3 days with clots.

Denies spotting, denies issues getting pregnant. 

Obstetric History: G1P1001

Psych/behavior: Appropriate and pleasant

Include three additional questions you would ask the patient or informant and state how that information would assist you in formulating a diagnosis.

1. Getting a better understanding of when the patient last had intercourse in order to consider pregnancy as a differential
2. Getting some more details on the patient’s fatigue and how it is affecting her quality of life and if it has any impacts on her daily activities
3. gathering more information on the patients stress level and uneasy feelings about going back to work.

Necessary Components for the Objective information:                                                      

Document all findings, avoid the word negative or normal. It is important that you learn to deduce that the patient has no remarkable findings.

Vital Signs: Temp 98.7 HR 78, BP 110/72, RR 14, SpO2 94% RA

Height/Weight/BMI: 5’6”, 140 lbs. BMI 22.6

Physical Exam

Constitutional/General survey: Well appearing young female, alert and oriented, dressed appropriately, in no signs of acute distress

Skin: Warm and dry, no rashes or lesions

Head: Atraumatic, normocephalic, no deformities

Eye: PERRLA, No swelling, ptosis or redness. No discharge. Visual acuity 20/20 bilaterally

Ears: Normal appearing externalauditory canals, no swelling or discharge. No hearing deficits

Nose: Symmetrical, no discharge or polyps noted

Mouth: Clear mucous, no abnormal breath smells, no hoarseness Neck: No deformities, trachea midline. Thyroid moves with swallowing Lymph nodes: Thyroid normal size and firm, no nodules palpated Thorax: Lungs are clear bilaterally.

CV: s1 and s2 auscultated, no murmurs rubs or adventitious heart sounds noted. Abdomen: Flat, symmetric. No deformities, lesions

Genitalia: Normal external genitalia, uterus size 9-10 weeks. Non-tender Peripheral vascular: Normal pulses +2, no swelling noted Musculoskeletal: Normal gait, reflexes +2 bilaterally

Neurologic: Steady gait, PERRLA, strength5/5 bilaterally. No rigidity

Necessary Components for the Assessment information:                                         

Iron deficient anemia

Anemia is the one diagnosis that can have a subtle onset and no clear physical findings. This along with the patient’s heavy periods with clots could be indicative of anemia due to blood loss. In a study by Kocaozet al (2019), it was determined that heavy menstrual bleeding is common and has negative effects on anemia, fatigue and quality of life. The patient also mentioned she misses work due to her periods.

Fatigue related to pregnancy

The patient uses latex free condoms which can be less effective. Although pregnancy is unlikely due to her recent period but it should be a differential and the patient should be tested. The patient’s uterus is also 9-10 weeks in size.

Fatigue related to uterine fibroids

Uterine fibroids would explain the enlarged uterus and heavy periods. Uterine fibroids are common in women of reproductive age; they are particularly prevalent among black women and are more often associated with severe symptoms in black women than in white women (Stewart, 2015).

Necessary Components for the Plan:                                                                                   This will depend on your findings and the assessment. The expectation is to include: Diagnosis: Iron deficiency anemia related to menorrhagia

Diagnostics: lab work - CBC, ferritin, TIBC, hCg plasma,TSH. Ultrasound pelvic Pharmacology: Levonorgestrel IUD

Education/Counseling: Levonorgestrel IUD education, Iron supplementation , and education on side effects of both

Health Promotion/Anticipatory Guidance:

Education on ultrasound to rule out uterine fibroids and what they are. Follow-up with OBGYN after results are in

Self-Assessment:                                                                                                             

I feel as though all boxes were covered during this comprehensive history and exam. It is clear that the patient’s recent change in period, increasing flow, and clots may have to do with her fatigue. It would have been helpful to build a rapport with the patient and maybe she would have been more inclined to say more details about

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