Jenny Year Woman Explained for Students (Easy Guide)
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Original Question
Jenny is a 59 year old woman who presents today for evaluation of her bones. She just had a DEXA scan 2 weeks ago and is in to discuss the results with you. She has no verbalized complaints of back or bone pain. Meds: Vitamin D3 10,000 IU daily; Crestor 10 mg daily; Enzyme Co-Q 10 200 mg daily; Allegra or Allegra D [1] most days in the AM; Combipatch 0.05/.25 twice weekly [since 2014], B12 1000 mcg daily; Tylenol ES [2] prn for back discomfort. No drug allergies. PMH—Dyslipidemia; B12 Deficiency; Vitamin D Deficiency; Seasonal Allergies; Lumbar Spondylolisthesis; No previous surgeries; menopause at age 57; stress fracture of right foot at age 27 from running; no other bone abnormalities. Social—no smoking or illicit drug use; rare alcohol use. She walks 40 minutes or runs 1.5 miles [one or the other 6 days per week]; she is a 5th grade teacher ROS: she denies pain, fatigue, fever, eats/sleeps well; states her back rarely bothers her—she does her back exercises most days; when it hurts [2] Tylenol will relieve the discomfort. No chest pain, palpitations, shortness of breath, no reportable GI symptoms—colonoscopy 3 years ago was normal; mammogram in July was normal. DEXA scan two weeks ago. She had her first DEXA at age 41 and it was essentially normal—1.2 above the mean in the spine and -.9 below the mean in the hips. Her second one was done September 10th [when she had her physical exam]. Results showed -2.0 in the L/S spine and -2.4 at the hip. Recent labs showed a normal CBC, normal TFTs, 25 Vitamin D level of 32; B12 800 pg; TC 206, HDL 40, LDL 109, Trigs 108. 98-78-16 120/70 65 inches tall 125 pounds Exam reveals a well groomed Asian female in no acute distress. Heart is regular in rate and rhythm; lungs are clear to auscultation. No scoliosis, kyphosis noted; normal gait and station; normal flexion and extension of hips and L/S spine. UE/LE strength is symmetrical 5/5 bilaterally Assessment _______40% Medical Diagnoses with ICD-10 codes Differential Diagnoses with ICD-10 codes Nursing Diagnosis/Health Maintenance or Social issue: Initial Treatment Plan ________20% Diagnostics/Laboratories ________20% Rxs ________20% Nursing Interventions / Education ______ TOTAL (100%)
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