Please reply to this case study/discussion post and explain how you might think differently about the types of tests or treatment options that your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position. Case Study EM 41-year-old-female S: CC: Irregular heavy periods HPI: EM is a 41-year-old-female patient who presents to the office with complaints of irregular heavy periods that have been ongoing for more than 12 months. The patient states that she has had three bleeding episodes which have similar to her period in the month of June. The onset of these symptoms began gradually approximately 12 months ago and have been getting progressively worse. She describes these episodes as severe with heavy clots bleeding through super tampons and heavy menstrual pads within an hour. She has also noticed increase weight gain over the past 12 months of more than 30lbs which she has been unable to lose with diet and exercise. Additionally she notes severe cramps that cause her to double over in pain for days at a time at the start of her menses. She has noticed increase fatigue and dizziness during these bleeding episodes. Nothing has made these symptoms better. Location: vaginal Quality: heavy with clots Severity: severe Duration: greater than 12 months Context: with irregular menses has bled 3 different times already in June Timing: gradual Modifying Factors: none Signs/ Symptoms: clots cramps weight gain Amount of time needed before changing a pad or tampon: 1 – 2 hours Getting up at night to change pad or tampon: Yes Feeling faint or dizzy: Yes MEDICAL HISTORY: Lyme disease Epstein- barr virus Anxiety Headaches/Migraines. Ovarian Cyst Fibroids. GYN HISTORY: Menstruation: Menarche at age: 14 Lasts: > 7 days Character of period: heavy Sexual Orientation: Heterosexual. SEXUAL HISTORY: Currently Sexually Active: Yes with men How long have you been with your current partner? greater than 5 years Number of sex partners in a lifetime: 1 – 5 Sexual Abuse: None PREVIOUS TESTS: Last Pap Smear: 02/2021 Last Pelvic Ultrasound: /2019 Monthly Self-Breast Exams: Sometimes. STD’s: NONE. OB HISTORY: Total Number of Times Pregnant: 1. Number of Pre-Term Births: 1 C-SECTION. SURGICAL HISTORY: Denies Past Surgical History. HOSPITALIZATION/MAJOR DIAGNOSTIC PROCEDURE: Preeclampsia 2014 FAMILY HISTORY: Maternal Grand Mother: Pancreatic Cancer. Maternal aunt: Breast Cancer. 2 Aunts and 1 Uncle cancer. SOCIAL HISTORY: Tobacco Use: Tobacco Use/Smoking Are you a nonsmoker? Yes Tobacco uses other than smoking Are you another tobacco user? No Sexual History: Sexual History Had sex in the past 12 months (vaginal oral or anal)? Yes Have you ever had a Sexually transmitted disease? No Details of Sexual History Are you sexually active? Yes Are you having any sexual problems? No Have you had any sexually transmitted diseases (STDs)? No Sexual Abuse History: none Drugs/Alcohol: Drugs Have you used drugs other than those for medical reasons in the past 12 months? No Alcohol Screen (Audit-C) Did you have a drink containing alcohol in the past year? Yes Points 0 Interpretation Negative Caffeine Intake: 1-2 cups per day Miscellaneous: Current/ Former Occupation: LEGAL ASSISTANT. Marital status: married. Living with spouse. Exercise: moderate. Diet: Regular. Caffeine: 1-2 cups per day. Occupational exposure: none. MEDICATIONS: Vitamin D ALLERGIES: Vancomycin HCl-Redman Syndrome Demerol Amoxicillin. ROS: GENERAL: Chills No. Fever No. Headache No. Fatigue No. Weight gain YES. Weight loss No. EYES: Double Vision No. Blurred vision No. Pain No. Discharge No. Itching and redness No. Red eye(s) No. NEUROLOGICAL: Dizzy Spells No. Numbness/tingling No. Tremor No. ENDOCRINE: Too hot/cold No. Tired/sluggish No. Excessive thirst No. GASTROINTESTINAL: Indigestion No. Abdominal pain No. Heartburn No. Nausea No. Vomiting No. Change in bowel habits No. Constipation No. Decreased appetite No. Diarrhea No. Hematemesis No. Rectal bleeding No. CARDIOVASCULAR: Varicose veins No. High blood pressure No. Chest pain No. Palpitations No. Swelling in hands/feet No. INTEGUMENTARY: Nipple discharge No. Persistent Itching No. Skin Rash No. MUSCULOSKELETAL: Joint Pain No. Swelling in your joints No. Arthritis No. GENITOURINARY: Painful/ Frequent urination No. Decreased urination No. Pain with urination No. Heavy Periods Yes. Painful Periods Yes. Lack of Periods No. VAGINAL DRYNESS AND PAIN No. Decreased libido No. Vaginal discharge/Itching No. Irregular menstruation YES. Abdominal pain/swelling No. Blood in urine No. Pain during/after sex No. RESPIRATORY: Frequent Cough No. Shortness of breath No. Wheezing No. Hemoptysis No. Sputum production No. HEMATOLOGIC/LYMPHATIC: Blood clotting problem No. Swollen glands No. Breast lump denies breast masses. PSYCHIATRIC: Are you unhappy with your life? No. Do you feel severely depressed? No. Have you considered suicide? No. Anxiety No. Depressed mood No. O: VITALS: LMP: 6/23/2022 BP: 122/86 mm Hg Wt: 163 lbs Ht: 5 ft 2 in BMI: 29.81 Index HR: 62 /min RR: 16 /min Temp: 97.5 F Oxygen sat %: 99 %. PHYSICAL EXAM: GENERAL APPEARANCE: No acute distress Well developed well nourished. NECK/THYROID: Neck supple Full range of motion No cervical lymphadenopathy. SKIN: No suspicious lesions warm and dry. EXTREMITIES: No clubbing cyanosis or edema. NEUROLOGIC: No-focal neuro deficits Motor strength normal upper and lower extremities Sensory exam intact. GYN Exam: Deferred due to vaginal bleeding. A: DIFFERENTIAL DIAGNOSIS: Menorrhagia with irregular cycle – N92.1 (Primary) Prioritize this diagnosis. The diagnoses checks for excessive bleeding and frequent irregular menstruation cycles which is the main experience undergone by the patient. The diagnosis applies to; irregular intermenstrual bleeding Menometrorrhagia Irregular-shortened intervals between menstrual bleeding and Metrorrhagia. Classified under code N92 – Excessive frequent and irregular menstruation Dysmenorrhea – N94.6 The diagnosis examines abnormal painful abdominal cramps during menses difficult menstruation and painful menstruation. Categorized under Pain and other conditions associated with female genital organs and menstrual cycle Weight gain – R63.5 The diagnosis checks on abnormal and excess weight gain. Diagnosis is categorized under miscellaneous disorders of nutrition metabolism fluids and electrolytes with or without mcc (640/641) Prioritize this diagnosis as it can result in irregular menstruation. Chronic fatigue – R53.82 The diagnosis applies to chronic fatigue syndrome NOS. The diagnosis is associated with over 6 months of tiredness recurrent fatigue diffuse musculoskeletal pain and sleep disturbances. Diagnosis is categorized under signs and symptoms with or without mmc BMI 29.0-29.9 adult – Z68.29 The diagnosis checks on body mass index for adults. The condition is associated with Adult bmi 29-29.9 Overweight adult with bmi 29-29.9 and Overweight with body mass index (bmi) 29.0-29.9. Diagnosis is categorized under factors influencing health status and contact with health services and Body mass index. Hormone imbalance – E34.9 The diagnosis is categorized under Endocrine disturbance NOS and hormone disturbance NOS. The diagnosis checks hormonal imbalance resulting from too little or too much hormones. Prioritize the diagnosis as it checks on weight gain and irregular menses. P: LAB/DIAGNOSTIC: LAB: CBC With Differential/Platelet CBC test: blood count Treatment: blood transfusion LAB: PTT Activated Diagnosis: Screening test Treatment: Direct anti-Xa LAB: Factor VIII Activity Diagnosis: The factor VIII assay Treatment: medication – Hemlibra® LAB: von Willebrand Factor (vWF) Ag Diagnosis: von Willebrand factor (vWF) antigen test Treatment: Desmopressin LAB: Prothrombin Time with INR (PT/INR) Diagnosis: PR/INR test prothrombin time (PT) test. Treatment: Supplementation of vitamin K or blood components. LAB: Vitamin D 25-Hydroxy Diagnosis: 25-hydroxy vitamin D test The Treatment: Nutrition – food rich with Vitamin D LAB: Lipid Panel Diagnosis: Complete cholesterol test Treatment: lipid-modifying medications HMG-CoA reductase inhibitors. LAB: Basic Metabolic Panel (8) Diagnosis: Basic metabolic panel CHEM-7 LAB: Thyroxine (T4) Free Direct S Diagnosis: Thyroxine test Treatment: Antithyroid Medications LAB: Triiodothyronine (T3) Test: total T3 test Treatment: levothyroxine/liothyronine therapy Antithyroid medications LAB: TSH Test: Thyroid function test Treatment: Synthetic thyroid hormone levothyroxine LAB: FSH Serum Test: follicle stimulating hormone (FSH) blood test Treatment: Surgery LAB: Progesterone Diagnosis: Serum progesterone CBC Treatment: Hormone replacement therapy LAB: Estradiol Diagnosis: Estradiol test Treatment: Vaginal Suppositories Rings and Creams LAB: Estrogens Total Test: Total estrogen test Treatment: Hormone replacement therapy (HRT) LAB: Thyroid Peroxidase (TPO) Ab Diagnosis: thyroid antibodies test Treatment: Antithyroid medications LAB: Sex Hormones Binding Glob Serum Test: SHBG blood test Treatment: Nutrition LAB: Testosterone Free and Total Diagnosis: screening test- total testosterone test Treatment: Testosterone replacement therapy LAB: Dheas ULTRASOUND: Pelvic ULTRASOUND: Transvaginal FOLLOW UP: Return in 2 weeks for vaginal exam and review Lab and US results. CONSULT: Will refer the patient for possible surgical consult for possible Tubal Ligation vs. Hysterectomy. THERAPEUTIC INTERVENTIONS: Hormone therapy (HT) EDUCATION: Proper medication hygiene and Nutrition. Diagnosis and treatment of this condition requires proper evaluation and examination of different characteristics. Proper results are achievable through proper examination of the condition. REFLECTION: As I progress through this practice I have begun to recognize the like treatments and possible diagnosis when patient these presenting complaints. Although would have rather obtained a pelvic/pap smear to help rule out other possible diagnosis such as STI. I do agree with my preceptor for wanting to start with this current treatment plan. REFERENCE: Bernardi M. Lazzeri L. Perelli F. Reis F. M. & Petraglia F. (2017). Dysmenorrhea and related disorders. F1000Research 6. ICD-10-CM. (2022). The Web’s Free 2021 ICD-10-CM/PCS Medical Coding Reference. Sundar S. Balega J. Crosbie E. Drake A. Edmondson R. Fotopoulou C. … & Walther A. (2017). BGCS uterine cancer guidelines: Recommendations for practice. European Journal of Obstetrics & Gynecology and Reproductive Biology 213 71-97.

error: Content is protected !!