PCI Assignment: Patient Presentation of Tamar Locklear

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PCI AssignmentPatient Presentation of Tamar
Locklear

• Michael Hromadka
• 9/22/04

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Chief Complaint

• Tamar Locklear is a 19 year old female with a
  chief complaint of dark urine and sore
  muscles.

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History of Present Illness

• One day prior to clinic presentation Tamar
  participated in a day of downhill skiing
• She needed to rest for a long time
• Had severe muscle cramps
• No joint pain
• Dark urine color, no trauma or seizure
• No chest pain

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HPI continued

• The pain lasted only during that day
• Decreased activity alleviated the pain
• Tamar denied headache or fatigue
• No dizziness or blackouts
• Urine is normal color today

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Allergies and Medications

• No known drug allergies
• Tamar is not currently using any medications for
  chronic illnesses
• She has had muscle cramps before and takes
  aspirin for any pain

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Past Medical History

• Surgery to remove her tonsils in 1999
• No other hospitalizations or surgeries
• Muscle cramps and dark urine for past 5 years
• Symptoms occur after physical activity

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Family History

• History of diabetes and hypertension
• On both sides of her family
• No family members with similar symptoms
• Her brother is very sluggish and not active

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Social History

• Tamar is a student at the UNC-Chapel Hill
• Tamar is a chemistry major
• Tamar is a non-smoker
• She drinks about 2 drinks per week
• Always uses protection during sex
• She has had 3 sexual partners

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Physical Exam/Vitals

• B.P. 122/73
• Pulse 70
• Respirations 13
• Temperature 99.0 F
• Patient had regular heart sounds

• No distension, guarding, or pain in the abdomen
• All reflexes were normal
• Pulses were found at all extremities
• All joints were flexible and normal

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Labs Complete Blood Count
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X-Rays

• A chest X-ray was done to determine any
  abnormalities with the heart, mediastinum, or
  lungs.
• The lower extremities were also X-rayed to
  determine if there were any fractures

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X-Rays of Lower Extremities
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Assessment/Differential Dx

• Tamars muscle cramps are due to a metabolic
  disease
• Causes abnormal muscle breakdown during exercise
• More tests must be conducted
• Determine which metabolic process is altered
• There are no bone fracture or joint problems

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Treatments

• Increased protein store allows

• Patient is advised to stop strenuous physical
  activity until more tests are done
• She is to eat a high protein diet in order to
  ensure muscle build-up

Increased muscle production