Simple # 13 - Annual physical for Elderly – Mrs.

Thompson

A 65-year-old previously healthy female, Mrs. Thompson, presents to the clinic for
her annual physical examination. Her history shows that she had a mitral valve
prolapse. She takes acetaminophen for headache very rarely and prophylactic
amoxicillin before going to the dentist. Upon physical examination, there is a grade
2/6 systolic murmur preceded by a click and it gets louder with squatting. In distal
and proximal interphalangeal joints, you can see Heberden’s and Bouchard’s nodes
bilaterally. She underwent Colonoscopy and a diverticulosis in sigmoid colon was
discovered. Bone densitometry was also performed and her t-score was consistent
with osteopenia, which was her final diagnosis. I learned from this case that a
periodic visit to the health clinic can be beneficial to a patient for reassurance of
good health and also help them achieve optimum health by taking into account their
individual risks (such as age, gender, etc.) in order to screen them for certain
conditions, some of which may cause morbidity and mortality. I learned the concept
of pay for performance, which gives financial incentives to physicians that adhere to
strict screening guidelines for patients at risk. Apart from physical exam and
screening, this case provided an excellent explanation of many statistics concepts
relevant to medicine such as sensitivity, specificity, likelihood ratio, odds ratio,
relative risks and so on. This case provides a good review of why t-scores and z-
scores are relevant. T score compares to the reference mean of a normal, young
individual while Z score compares to the normal individual with the same age. I
learned that hip measurements are a better predictor than the spine in predicting
risk of fracture. Mrs. Thompson was advised to take 1200 mg of calcium and 600
units of vitamin D per day and if that didn’t prevent bone loss then consider
bisphosphonates. Estrogens are not recommended since they are not protective of
undesirable cardiovascular events. Estrogens are also noted to increased incidence
of breast cancer and clots. Overall a great review of disease prevention.

fmCase # 17 - Post-menopausal with vaginal bleeding - Mrs. Parker

A 55-year-old previously healthy post-menopausal female, Mrs. Parker who has

been on hormone therapy for two years now presents to the clinic with two weeks
of unexplained vaginal bleeding. This case was similar to the simple # 13 case as
both women are post-menopausal and many screening guidelines are the same. One
important guideline I learned was for quantifying vaginal blood loss was by asking
patient how many tampons/pads she uses. I learned about different things that can
cause bleeding in a post-menopausal bleeding such as cervical polyps, endometrial
hyperplasia, endometrial cancer, and proliferative endometrium. I had seen a trans-
vaginal ultrasound but did not know that it was the most cost-effective test to rule
out endometrial cancer in those with abnormal uterine bleeding but tissue biopsy is
the gold standard for diagnosis. Her diagnosis of endometrial proliferation is no
surprise due to hormone therapy for menopausal symptoms. This case helped
reinforce concepts learned in the previous case.