unit 3 journal

Name:  Desiree J. Allen DOB 5/4/92

 Pt. Encounter Number:2

Date: 1/17/23

Age: 29

Sex: F

SUBJECTIVE

CC: 

“Heavy periods”

HPI: 

29 yo G1P1 Caucasian female, history of incomplete L2 spinal cord injury resulting in paraplegia. History of heavy flow since onset of menses and presence of symptoms for one quarter of her life, now soaking super absorbency pad every 3 hours. Menses lasts one week or more. Reports flow is lighter for a couple days leading up and few days at the end however 5-6 days of heavy flow. Associated symptoms include lower abdominal pain, headache, body aches, fatigue and digestive issues including nausea and bloating. Has been seen by physician in past. Work up included Transvaginal ultrasound last year, results normal and endometrial biopsy normal. Was prescribed progestin-only pill but had difficulty with medication compliance. Has tried increased water intake, rest, healthier eating and PRN Midol use with no improvement. Has not identified any pattern to worsening symptoms. Describes symptoms as intense, unmanageable, pain severity 8/10. Unable to use tampons due to limited mobility and seeking alternate method to shorten and lighten menstrual flow.

Medications: Flexeril 10mg TID PRN for muscle spasm

Ibuprofen 600mg PRN generalized pain

Allergies: NKDA

Medication Intolerances: none reported

Past Medical History: Incomplete spinal cord injury L2 x 1 year, menorrhagia

Chronic Illnesses/Major traumas Spinal cord injury 1 year ago due to MVA resulting in paraplegia, patient is wheelchair bound.

Hospitalizations/Surgeries Spinal cord decompression 2022 following MVA, hospitalized x 3 weeks followed by 30 stay inpatient rehab.

Term pregnancy (40 weeks) with normal spontaneous vaginal delivery 4 years ago

Preventative Health: Normal PAP one year ago. COVID UTD. TDAP 2 years ago.

Family History

Brother-PTSD

Mother-Hyperlipidemia

Father- HTN

Social History

Pronouns used -she, her, hers. Completed 4-year degree in telecommunications. Currently unemployed and on disability. Previously worked in sales for a radio station which she enjoyed and hopes to return to someday. She is married and lives in a ground floor, handicap accessible apartment with her husband and daughter. She feels safe in her home environment. Denies tobacco or illicit drug use. Reports only occasional EtOH use. She is sexually active with husband although she reports challenges due to limited mobility and decreased sensation. Due to limited mobility, exercise is limited.

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General

Well groomed, interacts appropriately. Denies weight changes but reports wanting to lose a few lbs .Reports fatigue during menses.

Denies fever, chills.

Cardiovascular

Denies CP, palpitations, denies edema. Does report limited cardiovascular exertion due to limited mobility.  

Skin

Denies skin breakdown, uses moisturizers on bony prominences and repositions frequently. Denies bruising.

Respiratory

Denies cough, SOB. No history of pneumonia or TB.

Eyes

Denies.

Gastrointestinal

Reports nausea, bloating and digestive issues during menses. Otherwise denies abdominal pain, N/V/D. Reports eating a healthy diet. Denies history of bloody stools.

Ears

Denies.

Genitourinary/Gynecological

Denies any difficulty with urination.

Reports heavy periods, states menses have always been heavy and now changes super absorbency pad every 3 hours.

Sexually active with husband, limited due to decreased mobility and sensation

Husband had vasectomy.

Last PAP 1 year ago, normal

G1 P1, normal vaginal delivery at 40 weeks gestation.

Nose/Mouth/Throat

Denies.

Musculoskeletal

Occasional muscle spasms and generalized pain, relief obtained with PRN Flexeril and Ibuprofen.

Breast

Performs monthly SBE, no lumps, bumps or changes reported.

Neurological

Responds appropriately, oriented x 4. Denies syncope.

Paraplegia BLE.

Heme/Lymph/Endo

Denies history of bruising. Never had blood transfusion. Denies history of anemia. Denies swollen glands.

Psychiatric

Denies depression and describes herself as positive person. Denies anxiety or history of suicidal ideation.

OBJECTIVE

Weight       105lbs   BMI 20.1

Temp 98.3F oral

BP 110/68

Height 5’2”

Pulse 82

Resp 14 SpO2 99%

General Appearance

Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. .

Skin

Skin warm, dry, clean, and intact. No rashes or lesions noted. No upward curvature of the nails.

HEENT

Mucous membranes pink and moist. No palpable lymph nodes. No palpable thyroid mass, trachea midline.

Cardiovascular

Regular rate and rhythm. Pulses 3+ bilaterally. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

BS active in all the four quadrants. Abdomen soft, nontender. No mass.No hepatosplenomegaly. 

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

Speculum exam performed, cervix w/o lesions. No visible discharge or blood in vaginal vault. Uterus anteverted, mobile, nontender.

Adnexa nontender, palpable bilaterally

Rectal exam reveals no mass, sphincter tone absent

Musculoskeletal

Wheelchair bound. Deep tendon reflexes absent bilateral LE.

Neurological

Motor and sensory exam absent BLE response.

Psychiatric

Alert and oriented x4. Answers questions appropriately. Mood and judgement appropriate.

Lab Tests

Beta quantitative HCG <5 mill/ML, urine pregnancy test negative

Gonorrhea/chlamydia testing-negative

Transvaginal US-anteverted uterus measures 64x20x34mm. Normal thickness endometrium 7mm. Early proliferative phase. Myometrium normal. Ovaries normal size and appearance bilaterally. Trace physiologic fluid in the cul-de-sac.

Endometrial biopsy-no endometrial hyperplasia or atypia present

Vaginal Wet Mount

Ferritin level-11-307 mcg/L, TSH1.2 miU/L, Free T4 0.9-2.3 ng/dl, Hemoglobin/Hematocrit-13.0g/dl/39%

Assessment

· Include at least three differential diagnoses-*****menorrhagia, missed abortion, STI, bacterial vaginitis, candida vaginitis

· Provide rationale for each differential diagnosis

· Final diagnosis-Menorrhagia

· Pathophysiology of primary and rationale for choosing as final

Plan

· ******Include these: Insert hormonal IUD (brand name Mirena), follow up in one month for string check and status of cycle,

· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion-******include discuss timed toileting and when to self cath, monitor for autonomic dysreflexia monitor for skin breakdowb

· Referrals

· Follow up