Casey Kilroy Ihuman Case Study

When presented with a chief complaint from a patient, there is need to have a record of analysis and diagnosis. Ihuman case study samples are important to help in providing answers to simulation questions based on diagnosis that is conducted. 

Here is a case study sample of Casey Kilroy 

Mrs. Casey Kilroy is a 50-year-old female retired Colonel. She has two daughters and a living father.

Referral: None.

Source and reliability: Self-referred; seems reliable

Chief complain: “I have been usually tired and a bit short of breath when I do heavy housework, but I thought I was just overworking”

History of Present Illness:

Mrs. Casey Kilroy who has had problems with tiredness, headaches, and lightheaded. Mrs. Casey has been having shortness of breath for the las several months. Also, she states that the first time that she felt tired was several months ago while playing golf. Kilroy indicates that she feels lightheaded every time she works on her house. She missed a colonoscopy las year. The symptoms get aggravated if she attempts to do more hard work. Besides the first symptoms she appears to have dry lips, especially at the corners of her mouth, and indicated that she is vegan. Due to the notification at the blood donation of possible anemia, she sought consult today.

Medication: Ibuprofen for arthritis, Antacids Allergies: None

Past Medical History:

Childhood: None

Adult: Arthritis, possible anemia.

Immunizations: All recommended immunizations administered.

Past Surgical History:

Iron-replacement was given during both pregnancies due to anemic state.

Obstetrical and Gynecological History:

G2P2, with normal delivery. 2 daughter living.

Psychiatric: None

Family History:

No family history of anemia. Her father has colon cancer.

Personal and Social History:

Mrs. Kilroy has two daughters. Her father has colon cancer. She is vegetarian, in this case, she eats plenty of fruits and vegetables. She has not been able to make heavy housework in her house and not being able to exercise properly due to the symptoms she develops since a few months ago.

Review of Systems:

General: Patient is tired, lightheaded, dry lips and occasional loose stools. Most of these symptoms appear after attempting to exercise or do anything that requires heavy physical capacity, like housework. 

Skin: Slight pale or: no jaundice, petechiaeor ecchymoses, warm, and dry.

Head: Normocephalic, atraumatic, no deformities, temporal arteries non-tender to palpitation, frontal, and maxillary sinuses non-tender.

Mouth, Throat and Neck: Lips dry with mild angular cheilitis observed. Neck with no visible scars, deformities, or other lesions.

Cardiac: No significant change while standing,squatting, during Valsalvamaneuver or with sustained handgrip.

Respiratory: No distension, scars, masses or rashes Anterior lung fields are resonant. Normal tactile fremitus.

Gastrointestinal:    No change in appetite, vomiting ,or bleeding. Frequent loose stools and occasionally diarrhea.

Urinary: Normal

Genital: Normal external genitalia, vagina, and cervix: no atrophic changes. Uterus            slightly enlarges and irregular but is not tender to exam. Ovaries nonpalpable.

Vascular: Normal1.0-1.4 ratio of ankle to brachial BP. Musculoskeletal: Normal bulk and tone, no rigidity.

Neurologic: Cranial nerves I-XII appear intact.

Hematologic: Possible anemia. Endocrine: No problems presented.

Psychiatric: No mood, anxiety, depression, tension, or memory problems.

Assessment:

1. Anemia, iron deficiency
2. Low iron
3. Hight TIBC
4. Low ferritin
5. Rheumatoid arthritis

Plan:

Colonoscopy/ EGD

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