A 62-year-old Caucasian female presents for a return visit for monitoring of arthritic pain in her knees. She has informed the medical assistant taking her vital signs that she wants to make sure that the nurse practitioner also checks out her arms and chest because she has noticed blood-like spots under the skin on her body that she has not had before. She notes having bruising in her past not related to injury that she attributes to taking quinine for leg cramps; when she discontinued the quinine, the bruising went away. She states that her knee pain has gotten better now that she is taking her prescribed naproxen twice a day. Just this morning, she noticed some dried blood on her pillow, and she thinks she may have had a nosebleed. Past medical history includes osteoarthritis and no previous surgeries.
She has two adult children who are away at college, and she is divorced.
Social History: She drinks two to three glasses of wine each night because she does not like being in the house alone, now that she is an empty-nester. She prefers to drink rather than taking sleeping pills. She was a two-pack-a-day smoker for 20 years until the age of 50.
Vitals Signs: Temperature 98.5°F, Pulse 88, Respirations 20, Blood pressure 128/80, BMI 24
Chief Complaint: I noticed small red blood spots on my arms and chest for a few weeks. I noticed blood on my pillow in the morning; I think I had a nosebleed.
Address the following: