Assignment NR 602 Week 7 Clinical Case- Heavy Menses
Assignment: NR 602 Week 7 Clinical Case- Heavy Menses
S
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
Assignment NR 602 Week 7 Clinical Case- Heavy Menses
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
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
Important information for writing discussion questions and participation
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Please read through the following information on writing a Discussion question response and participation posts.
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