Chief Complaint: Patient requests to stop Depo because it is making her feel sick and vomit ever since she started Depo.
HPI: Patient has been on Depo for six months, and last shot was July 13, 2018. Patient has complaints of a headache, hair loss, and vomiting. The patient says that her hair loss and headache started before starting Depo series.
PMH: HTN, Obesity, Anxiety
Allergies: Menthol, and Sulfa
Medications: Lisinopril, Metformin, and Buspirone (patient cannot remember her doses).
Social History: Denies history of STD’s, tobacco, ETOH, illicit drugs. The patient currently works and is married. The patient is sexually active and has low a risk of HIV. The patient is married and has six children. She also works part-time when she can find the time per the patient.
Family History: The patient stated that she was adopted so does not know anything about her familys medical history.
Health/Maintenance Promotion: Immunizations are up to date. According to the United States Clinical Preventative Services Task Force (USPSTF) guidelines, patients should use medications to treat their hypertension as well as non-pharmacological therapies to treat their hypertension. Some of these therapies are Reduction of dietary sodium intake, potassium supplementation, increased physical activity, weight loss, stress management, and reduction of alcohol intake (Agency for Healthcare Research and Quality, 2014).
General: No fever, chills, awake and alert.
Eyes: No diplopia, redness, irritation, or discharge.
Head: (+) headaches, No seizures, dizziness, or head trauma.
Respiratory: No chest pain, cough, no shortness of breath, dyspnea, or cyanosis, asthma or COPD.
Gastrointestinal: (+) abdominal pain, nausea or vomiting, diarrhea or constipation, or change in bowel habits, reflux improved, history of chronic hepatitis.
GU: No kidney stones, bloody urine, discharge or rash.
Musculoskeletal: No joint swelling, no history of arthritis, (+) back pain, muscle weakness or muscle problems.
Skin: No rashes, itchiness or other skin complaints.
Endocrine: No excessive thirst, no excessive heat or (+) excessive cold, (+) increased hair loss.
Immunologic: No tuberculosis, hepatitis, or recurrent infections.
General: Normotensive, in no acute distress, no coughing, cooperative, able to communicate no shortness of breath, no feeling tightness in the chest, morbidly obese.
VS: Weight 178 lbs. BMI 33.6 Temp 97.9 BP 138/86 Height 61 Pulse 68 Resp 20
Head: Normocephalic, no lesions.
Eyes: PERRLA. EOMs are intact. No conjunctival or scleral injection. Conjunctivae pink and sclerae anicteric, fundi without vessel crossing changes.
ENMT: Hearing: no hearing loss.
Neck: Neck: supple, FROM, trachea midline, and no masses. Lymph Nodes: no cervical LAD, supraclavicular LAD, axillary LAD, or inguinal LAD. Thyroid: no enlargement or nodules and non-tender.
Lungs: Respiratory effort: no dyspnea. Percussion: no dullness, flatness, or hyperresonance. Auscultation: no wheezing, rales/crackles, or rhonchi and breath sounds normal, good air movement, and CTA except as noted.
Heart: S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Abdomen: Abdomen normal; BS active in all four quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Back: Normal curvature, no tenderness.
Skin: Normal, no rashes, no lesions noted.
PV: No pain in legs, calves, thighs or calves while walking. Denies leg cramps, ulcers, ulcers,
varicose veins, thrombophlebitis, clots in veins, swelling of legs, coolness/discoloration of extremity.
MSK: Full ROM saw in all four extremities as the patient moved about the exam room.
Neuro: Speech clear. Good tone. Posture erect. Balance stable; gait normal. Monofilament normal. CN 2 -12 normal. The sensation of pain, touch, and proprioception normal. DTRs normal in upper and lower extremities. No pathologic reflexes.
The patient had a CT scan of her abdomen because of the pain that was ordered by her PCP. It was normal regarding the abdomen. It did show that the patient had a fatty liver. The patient also had an ultrasound of the right ovary because she was experiencing pain that was ordered by her OBGYN. The results were unremarkable.
Lab: The patient had blood work done with her PCP and forgot to bring in a copy of the bloodwork. Will bring in a copy at the next visit.
1. Essential Hypertension
2. Type II diabetes
3. Family Planning Consult
4. Body Mass Index 30-39
Plan: 1. The patient will stop depo series as of today.
2. Start Orthotricyclen low today.
3. RTC in 3 months for resupply.
4. Urine HCG negative.
5. Follow up with PCP for thyroid evaluation and fatty liver.
Diagnostics: The patient will be given a prescription for Orthotricyclen today.
Therapeutic: The patient wanted to switch from the Depo shot to taking pills. She believes that the shot contributed to her abdominal pain, headaches and hair loss.
Educational: The patient was advised to check her blood pressure the next time she has a headache. The headaches may be due to her blood pressure. The patient stated that she was having hair loss before she started on the Depo shot and it progressively got worse. Now she has the cold intolerance. The patient was advised to have her thyroid levels checked when she goes back to her PCP.
Consultation: The patient was referred back to her PCP to redo blood work and recheck her thyroid levels. She was also advised to go back to her OBGYN so that they can discuss any further treatment regarding her ultrasound results.
Clinical Decision Making
The pathology of hypertension is highly complex and multifactorial. Some physiological mechanisms are involved in the maintenance of normal blood pressure, and their derangement may play a part in the development of essential hypertension (Beevers, Lip, & OBrien, 2001). The kidney is both the contributing and the target organ of the hypertensive processes, and the disease involves the interaction of multiple organ systems and numerous mechanisms of independent or interdependent pathways. Hypertension is caused by increases in cardiac output or total peripheral resistance or both. Cardiac output is increased by any condition that increases heart rate or stroke volume, whereas peripheral resistance is increased by any factor that increases blood viscosity or reduces vessel diameter (McCance, & Huether, 2013, pp. 1132-1133). Factors that play an important role in the pathogenesis of hypertension include genetics, activation of neurohormonal systems such as the sympathetic nervous system and renin-angiotensin-aldosterone system, obesity, and increased dietary salt intake.
Depo-subQ Provera (medroxyprogesterone acetate) 104 is indicated for the prevention of pregnancy in women of childbearing potential (WebMD Rxlist, 2009). Depo-subQ Provera 104 must be given by subcutaneous injection into the anterior thigh or abdomen, once every three months. For women who are sexually active and having regular menses, the first injection should be given only during the first five days of a normal menstrual period (WebMD Rxlist, 2009). Always make sure the patient is not pregnant before receiving the shot. Some side effects of the medication are uterine bleeding irregularities, increased weight, decreased libido, acne, and injection site reactions (WebMD Rxlist, 2009). Some adverse reactions are a headache, intermenstrual bleeding, increased weight, amenorrhea, and injection site reactions (WebMD Rxlist, 2009).
The patient was very shy and hesitant about speaking because she thought her English was not good enough. Even though the patient spoke English, it does not mean, that he understands everything that pertains to his illnesses. When clinicians lack the linguistic and cultural skills needed, and interpreters are not available, patients may have to rely on medically inexperienced, bilingual relatives or non-medical staff, compromising the quality of care and worsening health outcomes (Meuter, Gallois, Segalowitz, Ryder, & Hocking, 2015).
Barriers to Care:
When the patient does not speak English, and the provider does not speak the language of the patient, then there is a real barrier. It is hard to know if the patient understands what if being conveyed to them as far as their condition and how to take their medication. When they say they understand, do they really or are they just going through the motions to get out. Failure to communicate the seriousness of risk properly can have negative consequences: patients may fail to comply with instructions or elect not to have potentially life-saving treatment (Meuter, Gallois, Segalowitz, Ryder, & Hocking, 2015).
While use of contraception is influenced by a complex set of factors, including access to medical care and the influence of social networks, providers have the potential to positively influence women’s ability to use contraception during health care visits, especially as all non-barrier methods of contraception require either a prescription or a medical procedure(Dehlendorf, Krajewski, & Borrero, 2014). When discussing family planning counseling with patients, it is important to discuss the type, side effects, and the desire for future fertility. They need to know all of their options and be able to make an informed decision.
This case was not complicated, but I found it a little interesting. The patient said she had her thyroid levels checks in June and all the symptoms she was explaining to us was the same ones that a patient suffering from hypothyroidism would have. When we questioned her about it, she said her bloodwork on her thyroid was normal. We advised her to have them retested again when she goes back to her PCP to make sure that nothing has changed.
Advance Practice Practitioner Role Analysis:
The patient switched to birth control pills, but the doctor didnt have a problem giving it to even though she has a history of high blood pressure. I asked him if he was concerned at all about this and he said the fact it was controlled he was good with his decision. I didnt know how he came to his conclusion that it was under control because he never asked the patient if she checked her blood pressure regularly, he was basing his decision on his vital signs from that day.