NR 602 Week 7 Clinical Case- Heavy Menses

NR 602 Week 7 Clinical Case- Heavy Menses

NR 602 Week 7 Clinical Case- Heavy Menses

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CC: Patient is complaining of irregular heavy menses with severe cramping

HPI: EM, 21 yo Hispanic G0 female presented for establishment of gynecological care. Pt is not sexually active. Her first menstrual period was at age 11. She has been on OCP since 17 yo due to her dysmenorrhea. Pt with irregular and heavy periods (accompanied with heavy cramping) that will come every 2-3 weeks. LMP started 9/5/17. She has never had a papsmear. She is currently on Ortho Tri-Cyclen for her dysmenorrhea for the past 2 years. Pt reports continued irregular and heavy menstruation. She has tried 3-4 other OCPs with little success. She has also tried Depot shots. Pt on iron supplementation for the past year after having to report to the ER in 2016 for heavy uncontrollable menses.

Pt reports increased fatigue, weight gain, dry skin, hair changes, polydipsia, nocturia, polyuria, and constipation.

She denies palpitations, dizziness, HA, SOB, CP, edema.

She has not had her labs checked besides her CBC in the ER in 2016

Pt with developmental delay, functions at 15 yo level per mother

Current medications: Ortho Tri Cyclen Lo daily for heavy menses

Ferrous Sulfate 325mg take once daily for anemia

 

Allergies: NKA

Medical Hx: Start of menarche at age 11

Up to date on all vaccinations

Developmental Delay

Iron Deficiency Anemia

Menorrhagia

Dysmenorrhea

NR 602 Week 7 Clinical Case- Heavy Menses

Social Hx:

Single, not currently sexually active

Non-smoker. Denies alcohol or illicit drug use

Occupation: Assists with afterschool program

 

Family Hx:

Father- prediabetes, High cholesterol

Maternal grandpa- DM

Maternal grandma- DM, CKD on HD

Paternal grandma- HTN

Paternal grandpa- HLD

 

ROS

General: Reports fatigue and weight gain, unexplained weight or weight loss, loss of appetite, fever, night sweats. Does report dry hair and hair changes

EENT: Denies difficulty hearing, sinus problems, runny nose, ear pain, facial pain or numbness

CV: Denies irregular heartbeat, racing heart, chest pain, swelling to feet or legs, pain in legs with walking

Resp: Denies shortness of breath, night sweats, cough, wheezing, sputum production

GI: Denies heartburn, constipation, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, bloody stools, change in bowel habits

GU: Denies painful urination, frequent urination, urgency

MS: Denies joint pain, aching muscles, swelling in joints, joint derformities or back pain

Skin:  Reports dry skin. Denies rash, itching, lesions or breast changes

Neuro: Denies headaches, double vision, weakness, change in sensation, dizziness, tremor, loss of consciousness

Psych: Denies insomnia, irritability, depression, anxiety, recurrent bad thoughts, mood swings, hallucinations, compulsions

Endocrine: Denies intolerance to heat or cold, reports irregular heavy cycles accompanied with severe cramping. Reports increased thirst, urination, constipation

Hematologic: Denies easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia

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NR 602 Week 7 Clinical Case- Heavy Menses

Objective

General: Normotensive, in no acute distress.

Head: Normocephalic, no lesions.

Neck: Supple, no masses, no thyromegaly, no bruits.

Chest: Lungs clear, no rales, no rhonchi, no wheezes.

Heart: RR, no murmurs, no rubs, no gallops.

Abdomen: Soft, no tenderness, no masses, BS normal.

Extremities: Warm, well perfused, no edema.

 

Diagnostics

TSH, FT4, CBC, Iron panel, A1C, CMP, lipid panel