Dalisay Edwards is a patient who gets to be reviewed and diagnosed as an ihuman case study. This is a report that reviews her condition and case from a medical perspective. The main goal of notes and assessments in ihuman cases is to give a brief but direct approach on medical cases.
Below is a an ihuman case study report for Dalisay Edwards
Dalisay Edwards – OBGYN
CC – Night sweats, sleep problems, amenorrhea, G2P2
Ovarian insufficiency / premature ovarian failure / craniopharyngioma? / prolactinemia / anovulation / pcos / turner / intrauterine adhesions /depression / drugtest!! / night terrors(psych)
Diagnosis – Ectopic pregnancy
Tests- FSH, PRL, cortisol-AM, TSH, lipid profile, MRI of head!!!/CT of head
2cc/10asc/3pmh/2sh
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Dalisay Edwards is a 42 year old G2P2 woman presenting with Night sweats and sleep problems and Amenorrhea since the death of her mother 1 year ago. She has reported 5lbs weight gain. Physical exam is unremarkable. The patient denies recreational drug use, cigarette use, or drinking alcohol.
- Dalisay Edwards is a 42 year old G2P2 woman presenting with Night sweats and sleep problems that started 1 year ago.
HPI: She reported Night sweats and sleep problems since the sudden death of her mother 1 year ago.
She also reports Amenorrhea which started “9 or 12 months ago” as well as 5lbs weight gain.
Meds: none.
PMP: Patient denies smoking, drinking, and recreational drug use.
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 80; BP – 122/62 (wide), RR – 12; T – 98.6F (37 C); SpO2 – 94%
Physical exam unremarkable.
Assessment/Plan
Test Results:
FSH: Consistent with post-menopausal levels
PRL: Normal
Cortisol AM: Normal
TSH: Normal
Free T4: normal
Lipid profile: Mild increased cholesterol, atherosclerosis risk
Fasting Blood sugar: 110 (Pre-diabetic)
Management Plan
Hormone replacement therapy
Lifestyle change (prediabetes, atherosclerosis risk)
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