Patient Diagnostic Plan

Name: M.G. S O A P Time:11.20 p.m.
Date:9/14/2017 Age:35 y/o Sex: F
SUBJECTIVE
CC:

I have excessive menstrual bleeding.”

HPI:

Mrs. A.C. presents to the office complaining of having increase in numbers of days and amount of bleeding since last 3 months , and since last week she is feeling weak , she is afraid being anemic again. She had in last year the same problem during 6 moths, and then the menstruations came back to normal She had anemia due to blood menstruations and treated with Iron. Now again the blood losses last 7 to 9 days and soaks through the tampons every hour for 4 hours in a row during at least 6 days. Denies painful intercourse or vaginal discharge. Past medical history of anemia 6 months ago due to heavy menstrual periods, treated with Iron and recover to normal hemoglobin 3 months ago when she visit her internist. She used ho have menstrual periods of 3 to 4 days with moderate amount. She is G3 P 3 LMP two weeks ago and has a copper IUD placed one year after her last delivery, 2 year ago. There is also no other discharge or pelvic symptoms in other days.

Medications:
None taken
PMH
Allergies: The patient states that she does not suffer from any environmental, food, or drugs allergies
Medication Intolerances:
There is no medical data about medication intolerances.
Chronic Illnesses/Majortrauma
She was found microcytic anemia
Prolonged menstrual periods
The patient denies having major traumas.
Hospitalizations/Surgeries:Three times for regular uncomplicated deliveries.
Family History
Father is alive. Negative for cancer, heart disease, hypertension, tuberculosis, other medical illnesses.
Mother is alive. Negative for cancer, heart disease, hypertension, tuberculosis, other medical illnesses
Social History
The patient is socially active. She is works cleaning buildings, practices jogging weekends. She does not use tobacco or drugs, she drinks one glass or two of red wine at dinner. She onlyhas sexual activity with her husband. She has good family relations with her children and husband..
ROS
General Cardiovascular
Last few weeks she feels no much energy
the patient has no problems with weight. She deniesweightloss/gain,fever,andnightsweats.
The patient does not have cardiovascular problems. She denies chest pain, PND, edema, orthopnea, etc. In the course of the examination, no symptoms or problems are discovered.
Skin
.No reports of rash,lesions,delayedhealing,bruising,bleedingorskindiscolorations. The patient denies an ychangesin moles.
Respiratory
There are no signs of problems. The patient deniesshortnessofbreath,cough,congestion,wheezing,hemoptysis,dyspnea,pneumonia.There is also no tuberculosis history.
Eyes
There are no reported problems with sight. The patient denies blurring, visual changes of any kind. She does not visit ophthalmologists regularly because does not feel the need for it.
Gastrointestinal
She has no complaints of gastrointestinal system. The patient denies hepatitis, hemorrhoids, eatingdisorders, ulcers, blacktarrystools.
Ears
The patients hearing is fine. She has never experienced ear pain, hearing loss, ringing in ears, etc. There are no signs of ear traumas.
Genitourinary/Gynecological

The patient suffers from increased and prolonged menstrual periods. The blood losses last 7 to 9 days and soaks through the tampons every hour for 4 hours in a row during at least 6 days. There is no unusual vaginal discharge. The patient denies bleeding between menses. There is an abdominal and back pain at the lower abdomen
Before the actual problem regularmensesevery28-29dayslasting3-4days.The first day of lastperiodwas10 days ago.

Menarche:12.Y/o G3 P3
No history o fSTDs or vaginal infections.
Pap Smear 8 months ago Normal.

Nose/Mouth/Throat

The patient does not have any oral cavitys diseases. She denies a sorethroat,discharge,dysphagia,nosebleeds,dentaldisease,hoarseness.

Musculoskeletal

The musculoskeletal development is normal. No signs of dystrophy. She deniestrauma, backpain,hippain.Deniesfracture.The examination does not demonstrate any visible problems in the sphere.

Breast

There are no signs of breast cancer. The patient denies lumps,bumpsorchanges.There is no breast cancer history in the family.

Neurological

Monthly headaches during her menses. A severe headache. She does not experience spontaneous episodes of weakness, memory loss, mental problems, etc.

Heme/Lymph/Endo

The patient is not a donor. She denies blood transfusion. There are no cases of extreme sweating, alterations in her appetite, etc .

Psychiatric

The patient feels anxiety before the menses starts. Demonstrates the fear of painful menstrual period. Denies depression, sleeping disorder, suicidal attempts, etc.

OBJECTIVE
Weight:147lbs BMI:25.2. Temp:97.1tympanic BP:110/80rightarmsitting
Height:5’4 Pulse:78 x min Resp:14 x min. Oxy Sat 98%
GeneralAppearance
Female not in distress cooperative answers willingly and appropriately.
Skin
The patients skin is of normal color. It is warm, clean, without spots or some other problems.
HEENT
The patients head is normocephalic. It is symmetric. There are no lesions. Her hair is distributed in accordance with the sex character. No tenderness. No signs of major traumas.
The patients eyes demonstrate no signs of significant health problems. Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. The sclera is clear.
Ears: Landmarks are visualized. No signs of problems with hearing. Positive light reflex.
Nose: No visible problems. Mucosa is fine and pink. There are no deviations.
Neck: Pharynx is pink. Oral mucosa is fine. Problems with occlusion that should be corrected
Teeth are fine. There are no nodules. Finally, no lymphadenopathy or thyromegaly are discovered. Oral mucosa is moist and pale pink
Cardiovascular
No extra sounds are discovered during the patients investigation. The rate and rhythm are regular. Capillary refill – 1,7 seconds. There is noedema.
Respiratory
The patients chest wall is symmetric. She demonstrates regular respirations. There are no problems with breathing.
Gastrointestinal
The patients abdomen is round, soft. Responds to palpation in a normal way. Active in all quadrants. There are no signs of visible health problems.
Breast
Breast exam proves the absence of health problems. No signs of breast cancer. No calcifications. The overall state could be described as normal.
Genitourinary
Externalexam:Vulvais pale pink,without any traumas or signs of damage. There is no discharge on the walls.. Pelvic examination shows vaginal mucosa pink, no secretions, os closed. Visible IUD chord, bimanual exam shows uterus retroverted no mases non tender.
Adnexa is palpable. Rectal exam demonstrates the absence of pain, mases or signs of traumas. No bleeding.
Musculoskeletal
The patient demonstrates no pain when moves. All gestures are painless. The locomotor apparatus is fine.
Neurological
The patients speech is clear. She responses to all answers in an appropriate way. Demonstrates an appropriate level of cognitive activity. Reflexes are intact. Balance is stable. No visible neurologic diseases.
Psychiatric
The patient maintains the eye contact. Speech is clear. Understands all questions. Demonstrates anxiety because of the pain during menses. No visible signs of mental disorders. The family history also does not contain any records of this sort.
Lab Tests (START HERE)
Ultrasound – the examination to create the image of the uterus, fallopian tubes and ovaries and discover inflammatory states. No clinical problems.
MRI – investigation of pelvic organs and their current state. No significant problems discovered.
Blood test – to investigate the chemical composition of blood.
Estrogen test – demonstrates the normal level of hormones
HIV infections test – no diseases discovered.
Special Tests
Laporoscopy
ASSESSMENT FINDINGS AND PLAN
  • DifferentialDiagnoses:

1. ICD-10Code: №92.1 – Excessive and frequent menstruation with irregular cycle (menorrhagia)
2. ICD-10 Code:№92.5 – Other excessive irregular menstruation
3. ICD-10 Code: N92. 6 – irregular menstruation, heavy bleeding

The problems the patient has could indicate several similar diagnoses. These are menorrhagia, other excessive irregular menstruation, or irregular bleeding. There are several causes for their appearance. These could be stress, use of various medications, poor nourishment, problems with pelvic organs, problems with hormones, birth control pills, etc. (Naftalin et al., 2014). That is why it is crucial to investigate the patients history.

She suffers from the increase in the number of days and amount of bleeding during menses. The patient refuses drug use. She has sex only with her husband. She uses IUD as the birth control method. Previously, she used to have anemia due to heavy blood menstruation. She used iron as treatment. At the moment, new cases of blood losses can be observed. The combination of these symptoms indicates the three above-mentioned diagnoses. However, menorrhagia is the most obvious diagnosis as the patient loses blood and needs special treatment to recover (Shaw, 2017).

To prove the diagnosis (menorrhagia), a specific set of actions is needed. First, it is important to assure that blood loss is not preconditioned by some other factors. MRI and ultrasound investigation should be used. These scans will indicate the presence or absence of inflammatory processes or other significant problems. Additionally, it is also crucial to monitor the endocrine profile as its alterations could result in the appearance of similar health issues. Therefore, to prove the final diagnosis, the impact IUD has on the patient should be investigated.

Presumptive Diagnosis: Menorrhagia

Plan:

  • Treatment
    • Extract IUD
    • Prevent further blood loss. Coagulants could be used (Lukes, Baker, Eder, & Adomako, 2012).
    • Restore iron
    • Monitoring

Education

The patient should be informed about the peculiarities of IUD use (“Intrauterine device (IUD) for birth control,” (2017). The use of the device as the birth prevention method could precondition the appearance of problems with menses. Irregularity, blood loss, pain, and other symptoms could be side effects (“What are the disadvantages of IUDs?” n.d.). It means that IUD is not recommended to the patient. The information about other birth control measures should be provided for her to choose the most convenient and appropriate one. Their impact on her health should also be explained.

Follow-Up-

  • The patient should visit the medical unit during the next menstruation period to note alterations in her state and their character.
  • In case another birth control method is chosen as the alternative to IUD, the patients state should be monitored to determine the impact the new method has on her health (Quinn & Higham, 2016).
  • In case hormonal pills are chosen, the endocrine level should be examined.

Self Assessment

The given investigation contributed to the improved understanding of the impact IUD and other birth control barrier methods might have on the state of a patient. Menorrhagia could become a serious health problem as it is followed by significant blood loss (Shahian, n.d.). For this reason, the approaches used to diagnose the given medical problem and help patients suffering from it were investigated. The case provided us with the knowledge that could be applied to similar issues.

References

Intrauterine device (IUD) for birth control. (2017). Web.

Lukes, A., Baker, J., Eder, S., & Adomako, T. (2012). Daily menstrual blood loss and quality of life in women with heavy menstrual bleeding. Women’s Health, 8(5), 503-511. Web.

Naftalin, J., Hoo W., Pateman K., Mavrelos D., Foo X., & Jurkovic D. (2014). Is adenomyosis associated with menorrhagia? Human Reproduction, 29(3), 473-379. Web.

Quinn, S., & Higham, J. (2016). Outcome measures for heavy menstrual bleeding. Women’s Health, 12(1), 21-26. Web.

Shaw, J. (2017). Menorrhagia. Web.

Shahian, T. (n.d.). Menorrhagia. Web.

What are the disadvantages of IUDs? (n.d.). Web.