UNIVERSITY OF IMMACULATE CONCEPTION

ENDOCRINE DISORDER CASE STUDY

Patient Drug Database

Patient name: Y-Ling Wang

Age: 49 Gender: FEMALE Race:
Height (cm): Weight (kg):
Allergies/Intolerances/ADRs:
Known drug allergies/ADR
Drug(s): Reaction(s):
Penicillin Rash

HPI, PMH, FH, SH, etc.

Chief Complaint (CC)

“I’m so tired lately. I have no energy. Maybe I need vitamins or something/”

History of Present Illness (HPI)

Y-Ling Wang is a 49-yeat old woman who presents to her new physician complaining of feeling tired,
lethargic, and “not thinking straight” for the last 6 months. She has seen her previous primary care
physician several times and has been told that her symptoms are probably due to anemia from
menorrhagia, stress, depression, and/or impending menopause. She was not entirely satisfied with
those explanations, and despite treatment with iron (and resultant improvement of her anemia), a
hormonal contraceptive to help regulate her menstrual cycle, and an antidepressant, her symptoms
have slowly worsen. Two years ago at a pharmacy student-run health fair, she was told her TSH was
6.2 μIU/mL (6.2mIU/L) and her total cholesterol was 246 mg/dL (6.36 mmol/L). Y-L’s primary care
physician felt the TSH value was compatible with subclinical hypothyroidism and therefore could not
explain her symptoms at that time. She has been wondering if she really is depressed and why the
depression medication is not helping. Over the past few months, she has also noticed that her skin
seems a little more dry and itchy and that she has difficulty keeping warm even in warm weather.
Finally, she asks you what is good for constipation since the Chinese herbs her mother gave her are
not helping.

Past Medical History (PHM)

Iron-deficiency anemia diagnosed 6 months ago
Depression x 6 months
Menorrhagia diagnosed 6 months ago
Osteopenia x 1 year

Family Medical History

Father had CAD and died of gastric cancer at age 74. Mother is alive at age 70 with osteoporosis and
hypothyroidism. She has one older brother who is healthy.
 UNIVERSITY OF IMMACULATE CONCEPTION
ENDOCRINE DISORDER CASE STUDY
Patient Drug Database

Social History
Came to the United States from China at age 15. Speaks Mandarin and English. Married and lives with
her husband of 24 years; has two children, age 22 and 19. Works as a language instructor at a local
community college.
Tobacco/Alcohol/Substance Use
Social drinker; (-) tobacco or illicit drug use

Medication List
Milk of Magnesia 30ml PO q 24 h PRN
constipation
Rhubarb (Chinese herb product) PO PRN
constipation
Sertraline 50mg PO q 24 h
Ortho Tri-Cyclen 28 PO q day
FeSO4 300mg PO q day
Calcium carbonate 1,000 mg PO bid
Alendronate 35mg PO weekly
Acetaminophen 650mg POO PRN headache, body
aches

Vital Signs, Laboratory Data, and Diagnostic Test Results

Date
Blood pressure 112/76 mmHg
Pulse rate 64
Respiratory rate 12
Temperature 26.2
Na 142 mEq/L
K
Cl 4.1 mEq/L
CO2 24 mEq/L
BUN 7 mg/dL
 UNIVERSITY OF IMMACULATE CONCEPTION
ENDOCRINE DISORDER CASE STUDY
Patient Drug Database

SCr 0.7 mg/dL

Glu 104 mg/dL
HBA1c
Hgb
Hct 39.7%
WBC 7.6 x 103 mm3
Platelet
AST
ALT