VT Presentation

CC. My stomach, muscles and joints are hurting. HPI: A 26-year-old female patient visited the clinic with abdominal pain. She reports having had no BM in the last two weeks. After seeing the ER Brookwood in Homewood on 11/22/22, she was discharged with no medication. The patient has hx of anemia and has been put on medication (Iron). Denies any rectal bleeding but reports the mother being diagnosed with breast and colon cancer at age 35.  Recent hx of muscle and joint pain from her shoulders and bilaterally down to her feet ( her pain is 7/10). Nothing has given her relief. Experienced burning pain for the last two months, with no medication making it better. The pain is recurrent. Denies hx of autoimmune disease in the family and herself. Not seen any provider except for the ER visit. ROS: Positive for abdominal pains, muscle weakness/arthralgias/joint pain, and neck and back pain.  Medical History: Iron  Surgical History: Endometrial ablation 08/10/21 and 08/21/2020. Family History: No complaints   Social History: No complaints Allergies: None reported. Medications: Ascorbic Acid(Vitamin C) 500mg  Colase 100mg Capsule.  Dulcolax (bisacodyl)10mg rectal suppository Ferrous Sulphate 325mg  Metamucil 0.4gm capsule. 2-4 capsules up to 4 times a day  Senna 8.6mg tablet. 2 tabs every day orally. Voltaren 1% topical gel. Apply 2 grams to the affected area 4 times a day. Physical Exam: Reviewed. Ht: 5 ft 10 in,  Wt: 175 lbs 7 oz , BMI: 25.2, BP: 110/76, Pulse: 78 bpm,  RR: 18, O2Sat: 99% Room Air Exam: GEN: (+)NAD HEENT: head normocephalic, atraumatic, EOMI, PERRLA, Visual Acuity WNL, normal dentition, normal lips, normal gums, pharynx unremarkableNECK: soft, non-tender, no significant cervical lymphadenopathy, Other findings: Supple, FOM WNLCV: RRR, no murmur/rub/gallop RESP: clear to auscultation bilaterally, no wheezes/rales/rhonchi, chest wall symmetric GI: NL abdominal inspection, bowel sounds intact throughout, no rebound/guarding/rigidity, (- )hepatomegaly, (-)splenomegaly, (-)masses (+) abdominal pain DERM: Other findings: Skin warm and dry EXT: full range of motion throughout MUSC/SKEL: muscle strength 5/5 throughout, Spine-NT; ROM WNL (+) mucsle pain, (+) joint pain, (+) muscle weakness NEURO: sensation grossly intact, CN II-XII intact and nonfocal, deep tendon reflexes 2+, bilaterally equal throughout, no pathological reflexes elicited, normal gait and station PSYCH: alert and oriented to time, place, and person, normal mood, normal affect Differential Dx. 1 Constipation- Patient has abd. pain and has not had bowl movement for 2 weeks  2 Abdominal pain, Joint pain with weaknes - Probable do to being constipated and h/o anemia 3 Anemia- could be source of weakness, muscle and joint pain  Assessment plan: Joint and burning pain: Voltaren Gel prescribed with instructions Constipation: OTC Meds, Colace for BM daily, fiber, Mag Caltrate, and fleets/ instructions provided ANEMIA: Instructions provided Nutrition regimen, diet and exercise regimen discussed Labs: Labs: CMP CBC with Diff/platelet Occult blood, FECAL, IA Discuss Mother's cancer hx. Advocate for obtaining genetic testing because of family history.  Anemia: To discuss lab results through telehealth. Pap is to be done on next visit.  Telehealth f/u on 12/13/22 Sam Jackson, NP Student