Case Study: Juanita

Patient Information: Juanita Morales is a 47-year-old G5P5LC6 Hispanic female. She presents with symptoms of lower abdominal cramping, urinary leakage, and cessation of menses for 8-12 months. She is well developed and well nourished but obese (BMI 45.89). She has a negative social history for alcohol, tobacco, and recreational drugs. Her last medical exam was several years ago.

Subjective

CC (chief complaint): Lower abdominal cramping and urinary leakage, along with fatigue, for the past day.

HPI: Juanita reports the abdominal cramping started several hours ago, is sharp, intermittent, and is increasing in frequency and intensity. She tried Motrin but it provided no relief. Her menses ceased 8-12 months ago. She also reports constipation, increased gas over the past several months, and a possible vaginal spotting several days ago.

Current Medications: None reported.

Allergies: No known drug allergies.

PMH: No past medical or surgical history reported.

Soc Hx: Negative for alcohol, tobacco, and recreational drugs.

Fam Hx: Not provided.

Surgical Hx: No history of prior surgical procedures.

Reproductive Hx: G5P5LC6, her menopause was "easy", last menses 8-12 months ago. Was using NFP for contraception before stopping her period.

Objective

Physical exam: Well developed, well-nourished obese Hispanic female in no apparent distress. There is potential for an abdominal mass, but this is difficult to assess due to her body habitus. The abdomen is otherwise soft and non-tender. Fungal dermatitis is observed under pannus.

Breasts: Pendulous, with bilateral white/yellow nipple discharge.

Abdomen: Obese, possible mass in the abdomen but difficult to assess due to body habitus, otherwise soft and non-tender. Fungal dermatitis under pannus.

CVA: No cva tenderness.

VVBSU: WNL, some watery d/c noted, nitrazine positive. Vagina with pink with rugae present. Good pelvic support, no cystocele or rectocele noted.

Cervix: Soft, smooth without CMT, os parous, slightly open.

Uterus: Difficult to assess due to body habitus, however, feels enlarged by bimanual exam.

Adnexa: Not palpated.

Diagnostic results: Urine dipstick showed SG 1.010, trace blood, neg nitrates, neg leukocytes, negative glucose, 3+ protein.

Assessment Based on the patient's age, clinical presentation, physical examination findings, and initial laboratory results, a few possible diagnoses...…imaging studies sooner, especially given the difficulty of physical examination due to the patient's body habitus.

Learning from this case, I understand the importance of comprehensive patient evaluation, including a detailed history and thorough physical examination, even when it is challenging due to factors like obesity. In a similar future case, I would also consider the need for early imaging and more immediate interventions due to the patient's weight and the potential for more complex conditions (Ahmad et al., 2023).

In terms of health promotion and disease prevention, this case highlighted the need for regular health check-ups, especially in the perimenopausal and postmenopausal age group. It also reinforced the importance of weight management and maintaining a healthy lifestyle to prevent complications associated with obesity. Considering the patient's Hispanic ethnicity, understanding the potential cultural and social barriers to health care access and promoting culturally appropriate interventions is crucial. Addressing diet and lifestyle modifications, including regular exercise, can also be beneficial in managing her current symptoms and reducing her risk for…