NR601 W5 Case Study
1
Apr 19 CCK, CU 041419MT
Mrs. Wong, a 59-year-old Asian female, presents to the office for a planned 3 month follow up
visit for her recently diagnosed right knee arthritis. She is experiencing less knee pain and
increased mobility with the treatment plan but reports some new concerns today. She reports that
she has been experiencing increasing fatigue for about the last 2 months. She is also gaining
weight since menopause 4 years ago. She has a health club membership and attends twice a
week. She walks on the treadmill at least 30 minutes as you directed and lifts light weights but
she has not lost any weight, in fact she has gained 4 pounds. She doesn’t understand what she is
doing wrong. She reports that exercise seems to make her even more hungry and thirsty, which is
not helping her weight loss. She requests evaluation as to why she is so tired and get some
weight loss advice.
Current medications: Tylenol 500 mg 2 tabs in AM for knee pain. Daily multivitamin and
turmeric. USES CBD oil for her knee, find it helps.
PMH: Has right knee arthritis diagnosed 3 months ago. Had German measles as a child.
Vaccinations up to date. Colonoscopy WNL 4 years- repeat in 10 years
GYN hx: G1 P1: daughter delivered@37 weeks, wt 8lbs 15oz. LMP 4 years ago. ASCUS pap
1998, all further paps WNL. Mammogram last year BI-RADS 1.
FH: parents deceased, child alive, well. No siblings.
SH: Divorced. works from home as an administrative assistant., 1-2 glasses wine one or two
times a week. Former smoker, quit 12 years ago.
Allergies: allergic to Bactrim, cats and pollen. No latex allergy
Vital signs: BP 112/76; pulse 80, regular; respiration 16, regular
Height 5’1.5”, weight 165 pounds
General: female in no acute distress. Alert, oriented and cooperative.
Skin: warm dry and intact. No lesions noted.
HEENT:. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and
intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate.
Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple.
Anterior and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid
midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no
abdominal bruits. No CVAT.
Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.
NR601 W5 Case Study
2
Apr 19 CCK, CU 041419MT
GU: bladder nontender upon palpation
Labwork: (fasting labs drawn this morning)
CBC: UA:
WBC 6,300/mm3 pH 5
Hgb 12.8 gm/dl SpGr 1.010
Hct 42% Leukocyte
esterase
negative
RBC 4.6 million nitrites negative
MCV 93 fl Glucose 1+
MCHC 34 g/dl Protein negative
RDW 13.8% ketones negative
CMP:
Sodium 136 Hemoglobin
A1C
6.6%
Potassium 4.4
Chloride 100 TSH 2.31
CO2 29 Free T 4 0.9 ng/dL
Glucose 127
Cholesterol:
BUN 12
Creatinine 0.7 TC 215 mg/dl
GFR est non-
AA
99
mL/min/1.73
LDL 144 mg/dl
GFR est AA 101
mL/min/1.73
VLDL 36 mg/dl
Calcium 9.4 HDL 32mg/dl
Total protein 7.6 Triglycerides 229
Bilirubin, total 0.5 EKG:
Alkaline
phosphatase
72
normal sinus rhythm
AST 25
ALT 29
Anion gap 8.10
Bun/Creat 17.7
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diagnosed right knee arthritis. was first posted on November 6, 2020 at 4:56 pm.
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