Regina Smith Year Explained for Students (Easy Guide)
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Original Question
Mrs. Regina Smith, a 34-year-old female, comes to the health care provider’s office with concerns about muscle weakness and lower back pain. She saw a specialist who gave her a steroid injection but it “didn’t help”. Past Medical History: Asthma, Type II Diabetes, Polycystic Ovarian Syndrome Past Surgical History: Denies Family History: Mother is diabetic and her father has hypertension Social History: Denies smoking, alcohol or drug use Medications: Mometasone 220mcg 1 inhalation every 24 hours Subjective Data: Has multiple bruises for no apparent reason Waxing her upper lip and chin frequently to remove excess hair No appetite Unexplained weight gain especially around her midsection Irregular menstrual cycles Feeling depressed Objective Data: Blood pressure (BP) 150/82 Pulse 90 beats/minute Respiratory rate 22 breaths/minute Temperature 99.6° F Pain 8/10 non radiating, aching lower back pain O2 saturation: 100% on room air Physical Exam: HEENT: Moon face, acne on forehead, hirsutism, extra fat around neck Neuro: Alert & oriented X 4 Cardiovascular: S1, S2 rate regular, 2+ pitting edema of lower extremities Respiratory: Clear to auscultation bilaterally GI: Truncal obesity ,+bowel sounds X 4 quadrants GU: Voiding freely Skin: Thin skin, multiple bruises on various areas of her body Extremities: Thin extremities QUESTIONS Which endocrine disease do you suspect patient R.S has? What is the most likely cause of this disease for R.S? What clinical manifestations of this disease is R.S displaying? What complications can arise because of this disease? What diagnostic studies/labs might be ordered for R.S? What will they show? What treatment would you anticipate the health care provider to order for R.S ? What is the primary goal of treatment? What changes will you make to R.S’ current medical regimen? R.S’s labs show: Cortisol 28 mg/dL (H) Glucose 265 mg/dL K 3.3 mEq/L Na 148 mg/dL Ca 7.8 mg/dL Testosterone levels elevated Which finding(s) is/are concerning and need to be reported to the provider?Why?
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