Health care maintenance items

/in /by

Health care maintenance items  A 45-year old African American female who was assigned male sex at birth, presents to the clinic as a new patient to establish care. She has no physical complaints, and is requesting medication refill as she has been out for 2 days. She is new to the area and recently had he belongings stolen while staying at a local shelter. she states the following ,medications are working well for her ad reports no intolerable side effects or adverse reactions :

Triumeq 1 tab PO QD

Estradiol 2 mg PO BID

Spironolactone 50 mg PO QD

Escitalopram 10 mg PO QD

Amlodipine 2.5 mf PO QD

 

1: Based on the in formation provided what are the differential diagnosis?

2: What history questions would you ask based on the information given?

PART 2

Ms. Copeland further details her history, She has struggled with her identity since her youth, also disclosing a history of depression she contributes to her years living in foster care. How ever 2 years ago she found comfort and clarity in a transgender support group in Seattle, WA. she states a concern for relapsing depression since she just moved to the ate and does not have a support group.

She started hormone therapy 1 year ago, and she has been happy since, and would like to continue treatment; she eventually would like to undergo gender affirmation surgery once her housing situation is stable.

She denies alcohol and recreational drugs, except for occasional marijuana. she is a tobacco cigarette smoker of 1/4 pps x 20 yrs. she discloses being in an open relationship with a male parter and is working as a prostitute. Her last STI check was aprox 6 months ago with no new abnormal results.

 

3: what screening tools would you use during today’s visit?

4: What focus physical assessment will you complete today?

 

PART 3

Objective

Bp: 12268, Pulse: 84, Temp: 97.2 F, Resp: 16, Ht: 6ft, wt: 164, BMI: 22.2.

PHQ9 total : 8, denies suicidal ideations

 

5: What is the diagnosis after physical exam and vitas?

6: will you fill her medications today?

7: What initial diagnose will you order? Include rational

8: what health care maintenance items should be addresssed.

9: what resources or patient education should you provide?

10: what is your follow up plan? what would Justify sending patient to higher level of care?

 

Thank you