Complaint of Dysmenorrhea, Essay Example

Client’s reason for coming: Non-specific autoimmune condition

41 year-old Caucasian female

Occupation: Mother, part-time medical assistant

Passions: Family, puzzles, knitting

Home Situation: Married to a man, two young children, ages 3 and 6, 2 cats, 1 dog

Client’s reason for coming:

Five years ago client suddenly presented with acute high fever and severe pain leading to hospitalization and severe intervention of high dose steroids. After almost 3 weeks in the hospital and investigation of various diseases she was diagnosed with a non-specific autoimmune condition. She remained on high dose steroids for almost two years, each time she lowered her dose the inflammation increased and she was hospitalized.

After almost two years, she became pregnant at which time she ceased the steroids and had no recurrence of the autoimmune disease while pregnant and 6 months later. After 6 months, she recently had a full recurrence with hospitalization and life threatening inflammation and fever.

Sleeps poorly, 4-5 hours per night and then can’t sleep anymore.  Bloodwork reveals elevated liver enzymes. Also concerned about cold hands and feet even when in warm places.

Body Type Client is observed as fairly deficient woman of average height and weight with typical steroid side effects in her appearance. She appears pale and fatigued, with dark circles under her eyes.

Tongue  pale, glistening with little coat, puffy with scallops.

Exercise no formal exercise, has 2 small children

CV Hypertension as a medication side effect.

Skin/joints Joints are painful and stiff at times.

Digestion Client reports limited digestive tolerance for foods. Reports raw foods, lots of vegetables and o most fruits cause her to have gas, distension, bloating and loose stools. Cannot tolerate fried or oily foods.

Urinary and Respiratory Nothing notable

Pshyc / Social Supportive family and colleagues. She is frustrated with her health and lack of medical care to support her condition.

Medications methotrexate 2.5mg, prednisone 40mg / day, beta-blocker

Herbs and Supplements none

Diet

• Breakfast toaster pastry, breakfast bar or donuts w/ coffee and orange juice
• Lunch Lean cuisine frozen meal, subway cold cuts or mcdonalds chicken sandwich.
• Snack Doritos, chips, funyuns
• Dinner pizza, pasta, lasagna or fish sticks always with texas toast
• Beverages diet coke or pepsi 48-64oz / day

Health Narrative

Client is frustrated with her current health state. Despite getting the best care she can find because of her location and connections within the medical community, she has never gotten better. Life “looks grim” and she can’t imagine how long she can “ live this way”.