FINAL CASE STUDY

MN577 Final Alternative Assignment

cc: “I restarted my period”

HPI: Alicia Baker is a 54-year-old African American female G2P1011 who presents to your GYN office as a new patient. She presents with complaints of restarting her period 5 days ago after she was told 2 years ago that she was “in menopause”. She uses pads, changing twice daily. She denies trauma, cramping or pelvic pain, no concerns for STIs and bleeding is not associated with sexual intercourse. She “feels fine otherwise”. This has never happened to her before and she is concerned. She brings no prior medical records for you to review.

PMH: Hypertension – well controlled on Lisinopril

PSH: nonruptured appendectomy as a child

Obstetric: Menarche age 11, menopause age 52. G2P1011, 2 pregnancies, 1 vaginal delivery, living child, daughter, 18 years old, 1 spontaneous abortion at 12 weeks gestation. Husband has had a vasectomy. LMP 2 years prior along with last WWE, pap WNL per pt.

Current Medications: Lisinopril 10 mg one PO daily

Allergies: Amlodipine - angioedema

FHx: Father – alive, HTN; Mother – deceased 3 years ago d/t CVA; oldest sister HTN, daughter 18 y/o healthy

SHx: married for 20 years, daughter away attending college

ROS

General/Constitutional: Mental Status: A&Ox4.

Skin/Breast: no complaints

HEENT/Neck: no complaints

CV: HTN, controlled on Lisinopril

Resp: no complaints

GI: no complaints

GU: no menses x 2 years until 5 days ago

MS: no complaints

Neuro: no complaints

Allergic/Immunologic: no complaints

Lymphatic/Endocrine: no complaints

Hematologic: no complaints

Psychological: the passing of her mother was difficult, she reports she is doing better now, supportive husband

Vital Signs

Skin: warm, dry

Temp: 98.5 F

Pulse: 72 bpm

BP: left arm sitting 124/60

RR: 16

SPO2: 99% RA

PE:

Skin: no lesions

Breast: no palpable masses, lumps, nodules in either breast; no breast discharge present

HEENT/Neck: no palpable masses, no adenopathy

CV: RRR, no murmurs, rubs, gallops

Resp: lungs CTA bilaterally

Abdomen: soft, nontender; no organomegaly; BS present x 4, no lymhadenopathy

GU: speculum exam reveals dark red blood of a moderate amount in the vaginal vault, cervix without lesions, uterus is anteverted, ovaries nonpalpable; rectal tone normal

Labs:

Pap: negative for intraepithelial lesion or malignancy

FIT: negative

UPT: negative

TSH: 1.3 mU/L

FSH: 58 IU/L

LH: 30 IU/L

Prolactin: 10 nanogram/L

AM cortisol level: 10 mcg/dL

H/H 13.2/36.0

Diagnostics:

Transvaginal ultrasound reveals endometrial thickness of 8 mm (normal <4 mm postmenopausal), ovaries unremarkable, no fibroids or fluid noted in cul-de-sac