Paper Example on Vaginal Bleeding Abnormality: 32yo Asian Female

Introduction

Problem Statement: "I am visiting this hospital majorly for a checkup regarding my vaginal bleeding abnormalities. It has taken a while before visiting a physician, an estimation of 3 and a half months from now. I am currently undergoing extreme bleeding as a result of my monthly periods, and this is making me weak and interferes with my daily schedule both at home and at work.

SUBJECTIVE DATA HPI

A 32 years old Asian female appears today for a medical checkup concerning her menstruation abnormalities. Patient remarks that she is in a healthy state of "perfect health." However, Reports that she experiences an occasional notice of irregular bleeding and excessive pain during her monthly periods this must be issued with Menorrhagia, but the condition does not give her any health difficulties. She again reports irregular episodes of diarrhea that she seems to attributes to stress (no current symptoms). She further denies any form of the chest or abdominal pain. She accepted nausea experiences. No recent weight gain/loss. She consumes regular diet and has not altered it recently. However, she claims that she is having for periodic inflaming eyes, and cold, but she shows no signs of such symptoms

Medications

Pertinent Medical

Refuses to affirm any long-term medical situation. Vaccination up to date (last TD 2008). States passed 5mm kidney stone 2008. Left wrist breakage (due to basketball) in 2010. Deterrent screenings: diabetes (none). The patient does not require diabetes screening since she hates the opinion- last eye assessment 2015, recent dental assessment 2012.

Contemporary Medications

Rx/OTC Prescription and, naproxen 500mg PO prn wrist pain. Terminate anytime.

Allergies

Allergic skin conditions such as eczema

Autoimmune progesterone dermatitis (APD)

Past Medical History (PMH)

Immunizations up to date (last TD 2008). States passed 5mm kidney stone 2008.

Past Surgical History (PSH)

She had gone through Ureteroscopy

OB/GYN History: The patient always experiences the presence of clots and forcing her to use many pads during her monthly periods. It sometimes forces her to be absent at job place due to excessive fatigue and weaknesses due to too much blood loss from her body.

Menstrual History

The female patient, 28 years of age, complaint that her June menstruation was late and the previous menstruation was in May. Her Menarche took place in junior high school, regularly three days ahead of each of her period. Too much bleeding in the first three days, and followed with a mild headache and back pains.

Contraception

Current method and satisfaction is extended oral contraceptive (seasonale) on daily dosing of ethinyl estradiol 0.03mg and levonorgestrel 0.15mg3

Cervical and Vaginal Cytology

not examined

Infections

No history of STIs, vaginitis, or PID

Fertility/infertility

Sexually active and fertile

Sexual History

Sexually active and has a monogamous sexual partner. She is straight and engages in sexual intercourse thrice a week. Never conceived or examined with any form of STI currently. However, she admits having contracted gonorrhea when she was in college (no symptoms present now or any adverse effects due to timely treatment).moreover. She never uses any substance in her life.

Obstetric history

The patient has been admitted to the clinic in regards to other medical complications and has had to go through a surgery. She has a healthy diet. She does not smoke or drink alcohol.

Personal History

The patient describes her condition to be in a perfect situation. She neither drink or. The patient is single and with no kids. She is physically active when free from work and even takes part in gym instruction classes and routine aerobic practice. She admits that she regularly monitors her fat and caloric consumption, and is on a healthy diet. Even though she has no close relation or dating, she is sexually active. She denies to ever using any form of recreational drugs current but admits that she once used some when in college.

Health Maintenance

Comprehending a menstruation cycle sheet to be in a position to detect any abnormalities whenever it occurs

Always carry out an exercise

Maintaining a healthy diet.

Regular medical check-ups

Immunizations History

never examined

Significant Family History

Mother passed on at 63 years of age from uterine cancer problem; father is alive, currently at the age of 72 and has a history of atherosclerosis. Nonetheless, she has two siblings, sister, 31 and a brother, 47 years old. The brother has a medical history of type 2 diabetes but in perfect health condition.

Objective Data

Review of Symptoms

General: Reports in a healthy state of "perfect" health. Dismisses headaches, recent change in weight, weakness or pain. She remarks that her last somatic examination was conducted in 2017.

Skin: Never experienced new skin eruptions or alteration in the feeling of her skin.

HEENT: Repudiates constipation and issues with eyesight or hearing. However, she puts on reading spectacles, last eye assessment in 2016. Never used hearing aids and dismissed cataracts and regular nasal blockage, nonetheless, having interval periodic watery eyes, and runny nose. (Showing no symptoms now). Contradict nosebleeds and either permanent or removable dental prosthetics; Last dental examination carried out in 2014(Cameron & TurtleSong, 2002).

Neck: Trachea midline.

Breasts: check-up: no gynecomastia, nipples symmetrical, no drainage.

Respiratory: She contradicts the history of lung disease, allergies, orasthms and any episodes of shortness of breath.

Cardiovascular/Peripheral Vascular: No cardiovascular problems such as high blood pressure, rheumatic fever, heart murmurs, palpitations, or chest pain. No preliminary stress test.

Gastrointestinal: not examined

Genitourinary: Dismiss frequent urination, delays, or inflammation when urinating. History of getting diagnosed with kidney stone 2008. She has been single for over three years and no sexual problems.

Musculoskeletal: Left wrist fracture (basketball, non-displaced) 2010. Irregular pain on the hand that she ascribes to participating in sports and no traumatic circumstance. Dismiss any other form of injuries such as orthopedic injury or arthralgia.

Psychiatric: Dismiss difficulty in paying attention, nervousness, and anxiety. No trouble in either falling or staying asleep. Periodically, (twice a week) waking up earlier to urinate (attributed to the intake of too many fluids at night before bed). Contradicts instances of mood swings, hearing voices, conventional sense of unhappiness, or need to attack self or others. No experiences of nightmares, extreme life stress, or memory loss. No loss of close friends or family member recently

Neurological: No medical history regarding stroke, seizures, or regular headache. No tremors ever recorded.

Hematologic: Dismiss thyroid issues, heat or cold bigotry, extreme hunger, thirst, but has a history of diabetes with her family. Contradicts regarding bruising and ease of bleeding.

Abdomen

Consistent diet. No swallowing challenges. Dismiss issues with sickness, dyspepsia, or food bigotry. Normal diet and no current alteration in heaviness of the body. Decline in any form of terrible diarrhea; however, she has self-limiting episodes of diarrhea that she ascribe to stress.

Moreover, reports occasional accounts with issues of blood clots noticing traces of blood on the sanitary pads.

Endocrine: Dismiss intensity edema, coldness, or leg cramps.

Allergic/Immunologic: experiences several skin condition during her periods due to allergy

OBJECTIVE DATA

Reports in a healthy state of "perfect" health. Dismisses headache, new weight alteration, fatigue or pain (Weiss, Lara-Torre,Murchison, & Spotswood, 2009).

Physical Exam:

Vital Signs: BP left arm sitting. 152/92HR 72RR 16Sa02 99% on room air

Tympanic temp 98.7

General: excessive and prolonged bleeding

Skin: regularly experienced recent rashes or alteration in her skin texture. Consistent clour of skin with race. Peripheral cyanosis and with unusual rashes. Various tiny (<0.5 cm) leveled hyperpigmented lesions on abdomen.

Neck: Thyroid and lymph nodes not palpable. Trachea midline.

Lungs: Lung fields not palpated. Anterior and Posterior lung fields free of auscultation.

Heart: Carotids never examined. No JVD at 90 degrees.

Peripheral Vascular:

Abdomen: Non-distended and round and without scars. No abdominal fondness to palpation. Liver and spleen are never palpable. Here are normative tympanic bowel sounds x 4, with no abdominal bruits.

Neurologic:

Mental status: aware, composed. No anxiety identified. Motor System: Muscle strength 5/5 in all extremities bilaterally. Gait stable w/o ataxia. Sensory: Sharp, uneventful, light in all severities examined with no deficiency. Reflexes: Triceps 2+ 2+. Biceps 2+ 2+, Brachioradialis 2+ 2+, Patellar2+ 2+, Ankle 1+ 1+. Babinski never examined.

Genital/Rectal: not assessed

Musculoskeletal: Muscles effectively progressed. Distal pulses +2. Capillary refill < 2 seconds.

Lymph Nodes: Not palpable in head or neck

Lab/Diagnostic Tests and Results: (example)

Pap smear test- results negative and no cell changes were found on cervix based on the HPV test

Vaginal culture- A vaginal smear examination result was positive with pH lesser than 4.5.

TSH, T3, T4, BMP, CBC, HA1C, PSA (all well).

ASSESSMENT

Most critical stage 1 hypertension

Various congenital/dysplastic nevi

Cervical cancer

Periodical allergic rhinitis

Irregular non-bloody diarrhea of unnoticed etiology

Differential Diagnosis (DDx):

Polycystic Ovarian Syndrome (PCOS): is a disease which that a woman's hormone levels and making her to produces higher than regular quantity of male hormones; therefore, resulting to skipping of monthly periods and it becomes challenging for such women to become pregnant.

Endometrial hyperplasia: is a situation in which the uterus lining tends to be unusually thick. It may facilitate uterine cancer in some women.

Endometriosis: is an infection in women which tissue similar to the tissue that makes the uterus lining grows outside of uterine cavity. And mostly cause the area to be inflammatory.

Final Diagnosis: Menorrhagia was obviously the terminal diagnosis in which a patient experiences a prolonged bleeding during her monthly periods.

PLAN /Medication

PLAN

Two days BP monitoring with a plan to introduce ACEI if stays elevated

Dermatology referral for assessment of various hyperpigmented skin lesions

Debated on the fundamental of cervical screening, intermittent diarrhea. Demonstrated on the application of procedural anesthesia alternatives.

Azelastine nasal, 1-2 sprays at the time of allergy season.

Initiating referral to other specialists like gynecologist in complicate cases

Conducting health promotion by education women on their health and sanitation to prevent further contraction of diseases.

The Follow-Up Parameters:

Follow-up once every week

Reflection:

From the case study, I have learned about abnormal menstruations and what to do about them in several situations. The treatment and caution to take to prevent the condition. Due to the case study, I can now practical educate patient on the re...