Medical Diagnosis

Case Study Four
Present Illness

Mrs. Sakay is a 46-year-old Filipino woman with several complaints. She has migraine headaches (HA) every month before her menstrual period. She rates the unilateral temporal pain as 8 out of 10, and this is associated with nausea and occasional vomiting. She prefers to be in a dark, quiet room when the pain starts. Sometimes she cannot take migraine medication, as she awakens with a migraine and is already nauseated. She denies aura, paresthesias, visual changes, sinus symptoms, or dizziness.

She tells you that her right hip is bothering her. She was hit by a car in her teens and has arthritis in that hip. She rates the pain as 7 out of 10 prior to taking ibuprofen and 5 out of 10 an hour after taking it. Partial pain relief lasts only about 2 hours. She denies other joint pain, morning stiffness, and fever.

She does notice that her hip feels stiff after sitting for a while, but it loosens up after a few steps.
She reports burning in her stomach that seems to be worse after she takes Excedrin® or ibuprofen, which is somewhat relieved by food and worsened by caffeine. The stomach pain occasionally awakens her at night. She denies dark stools, alcohol intake, and nausea and vomiting not associated with HA.

Her final complaint is that her menstrual periods have become heavy and somewhat irregular the past 6 months. She bleeds for 10 days with clotting the first day. Tampons last 1 to 2 hours on the first day. Her cycles range from 25 to 40 days. She denies dysmenorrhea, abdominal pain, orthostasis, vasomotor symptoms, or a new sexual partner.

Medical History

Infrequent migraine headaches since her 30s

Family History

Her parents and siblings are in the Philippines. She explains that she has no way of supporting herself since her divorce.

Medications

Over-the-counter Excedrin® Migraine without relief
Ibuprofen 200 mg, 3to 4 tablets tid for the hip pain

Allergies

None reported

Social History

Recently divorced with two grown children; has no close relatives in the United States

Physical Examination

This is a w/d, w/n female, who is 5 ft tall and weighs 130 lbs.
BP 110/70 sitting & 106/72 standing, P - 96, BMI - 25
Neurological exam was unremarkable; chest cta, cardiac nsr, abd soft and nontender.

Labs

Her stool is guaiac-negative.
CBC
Hemoglobin - 10 (12.1 - 15.1)
Hematocrit - 30 (36 - 44)
RBC - 3.0 (4.0 - 5.0)
RBC indices
MCV - 72 (80- 100)
MCH - 23 (27 - 31)
MCHC - 30 (32 - 36)
RDW - 17% (11.5 - 14.5%)

Radiology

The X-ray of the right hip reveals joint space narrowing and osteophytes consistent with degenerative joint disease.