Introduction
Patient diagnosis and development are important processes in the provision of care. It starts by taking subjective data from patients to understand the problem. Upon conducting a series of evaluations, the symptoms showed that she might have a uterine fibroid. Therefore, the patient was given some medication after a series of diagnoses.
Demographic Data
Patient B is a 34 years old Asian female.
Subjective Data
- Chief Complaint: “For the past one week, I have experienced unending backache, constipation, frequent urination and difficulty in emptying the bladder.”
- History of Present Illness (HPI): The patient came to the hospital for medical attention. Firstly, she reports heavy menstrual bleeding for one year now. Secondly, she complains of periodic back pain that resolves upon taking a painkiller. The patient denies being aware of anything that aggravates the pain, such as carrying heavy objects. She rates the pain at 7/10, which is considered severe.
- Past Medical History (PMH):
- Medical or surgical problems: she denies past medical or surgical problems
- Hospitalization: she was hospitalized for pregnancy complication
- Medications: ibuprofen 200 mg to alleviate pain
- Allergies: no known allergies
- Immunization: reports being up-to-date with all vaccinations
- Preventable health maintenance: denies being under a health maintenance program
- Family History:
- Father died at the age of 70 due to heart-attack
- The mother underwent a myomectomy three years ago to remove the fibroids.
- Social History: The patient is a 34 years old female living with her husband and two children, a boy and a girl, at their home. She works as a receptionist in a successful corporate organization where they are paying her well. In addition, she reports engaging in regular physical exercise, such as morning runs. The patient stated that she has a healthy sexual relationship with her spouse and ensures they eat a balanced diet.
- Review of Systems (ROS) as Appropriate: she reports regular visits to the optician and dentist and takes relevant vaccines such as COVID-19. She went for a colonoscopy the previous month for a routine check-up.
Objective Data
- Vital signs:
- Blood pressure of 187/112 mmHg.
- RBC of 2.5 M/ul.
- Heart rate of 105 beats per minute.
- Physical Findings:
- A firm palpable uterine mass.
- A distended abdomen.
Assessment
- Medical History: The history of the patient is analyzed to find any sign of fibroid. An individual with a family member diagnosed with fibroid has a high risk of having the same condition.
- Palpation (physical examination): It involves feeling a patient’s abdomen and pelvis to detect any sign of fibroid, such as a distended abdomen.
- Ultrasound: The condition can be detected by performing an ultrasound examination, usually through vaginal ultrasonography.
- MRI: the diagnosis is normally used when other tests are not giving clear information about the condition.
Plan
Diagnosis Plan
- A blood test will be conducted to determine blood count.
- Blood pressure and heart test will be done.
- Ultrasound will be performed on the patient. Alternative techniques such as the use of MRI will be engaged if the information is unclear (Uterine fibroids – Diagnosis and treatment, 2021).
Treatment Plan
- Gonadotropin-releasing hormone 0.25 mg tablet per day for 5 days (Badiani et al., 2018).
- Acetaminophen 500 mg tablet taken 3 times a day.
- Lisinopril 5 mg is taken once a day (Bækdal et al., 2019).
Education
- Educate the patient about the importance of completing the dosage in managing the condition. For example, the patient needs to take the medication based on how they are indicated for effectiveness (Uterine fibroids – Diagnosis and treatment, 2021).
- Encourage the patient to eat low-fat foods low in saturated fats and stop eating red and processed meat. She should also eat more fruits, vegetables, whole grains, and fish.
Follow up
The patient should come for a check-up after one week.
Health Maintenance
The patient is advised to be up-to-date with screening.
Conclusion
After a series of diagnoses on the patient, the uterine fibroid was confirmed. A treatment plan was administered, and the patient was advised to complete the dose. In addition, she was informed about the benefits of taking the medication seriously.
References
Badiani, B., Chiumente, M., & Messori, A. (2018). Ulipristal acetate for pre-operative management of uterine fibroids: Modeling outcomes and costs.European Journal of Obstetrics & Gynecology and Reproductive Biology, 222, 84-88.
Bækdal, T. A., Borregaard, J., Hansen, C. W., Thomsen, M., & Anderson, T. W. (2019). Effect of oral semaglutide on the pharmacokinetics of lisinopril, warfarin, digoxin, and metformin in healthy subjects. Clinical Pharmacokinetics, 58(9), 1193-1203.
Uterine fibroids – Diagnosis and treatment – Mayo Clinic. (2021). Mayo Clinic.