NU576 Unit 5 Journal

NU576 Unit 5 Journal

Student Name

NU576 NP II – Primary Care of Women’s Health

Prof. Name:

Date

NU576 Unit 5 Journal

A 37-year-old female presenting with irregular menstrual changes is most likely experiencing a hormonal imbalance, with Polycystic Ovary Syndrome (PCOS) being the primary suspected diagnosis. Further evaluation with laboratory testing, pelvic ultrasound, lifestyle assessment, and gynecological follow-up is recommended to confirm the diagnosis and guide treatment.

Patient Information

Patient Name: Cindy Haas
Encounter Number: 1524523
Date of Encounter: September 26, 2023
Age: 37 years
Sex: Female

Chief Complaint

The patient reports, “My periods are wacky, and I would like to figure out why.”

History of Present Illness

The patient is a 37-year-old female presenting with abnormal menstrual patterns that began slightly over one year ago. She reports experiencing shorter menstrual cycles lasting approximately 2–3 days and requiring only 1–2 pads per day. The symptoms began after discontinuing birth control.

The patient experiences lower abdominal cramping during menstruation but denies other abdominal symptoms. She has attempted management with prenatal vitamins and acupuncture without significant improvement.

The severity of concern is high due to the patient’s desire to identify the underlying cause of her abnormal bleeding pattern.

Current Medications and Allergies

Medications:

• Over-the-counter prenatal vitamins

Allergies:

• Sulfa drugs causing rash

Medication Intolerances:

• None reported

Past Medical History

The patient denies:

• Chronic illnesses

• Major trauma history

• Previous hospitalizations

• Surgical history

Family History

The patient reports:

• Mother: Diabetes mellitus

• Father: Hypertension

• Sister: Recently diagnosed with Type 2 diabetes mellitus

Social History

The patient has been married for 10 years and works as a teacher at Washington High School, where she has been employed for 15 years.

She reports:

• No tobacco use

• Social alcohol consumption, including wine on weekends

• No recreational drug use

Review of Systems

General

The patient denies weight changes but reports increased fatigue. Hair appears thinner than usual.

Cardiovascular

Denies:

• Chest pain

• Palpitations

Respiratory

Denies:

• Cough

• Congestion

• Shortness of breath

Skin

Denies:

• Bruising

• Rashes

• Skin discoloration

The patient reports dry skin on examination.

Eyes

Denies:

• Blurred vision

• Vision changes

She does not use corrective lenses.

Gastrointestinal

Denies:

• Nausea

• Vomiting

• Diarrhea

• Constipation

Reports abdominal cramping only during menstruation.

Genitourinary and Gynecological

The patient denies urinary symptoms, including burning or difficulty urinating.

She is sexually active with her husband and reports abnormal vaginal bleeding.

Ear, Nose, Mouth, and Throat

Denies:

• Sinus concerns

• Difficulty swallowing

• Throat pain

Musculoskeletal

Denies:

• Back pain

• Muscle pain

• Stiffness

Breast Health

Denies breast changes. She does not perform regular breast self-examinations.

Neurological

Denies:

• Weakness

• Dizziness

• Seizures

Hematologic, Lymphatic, and Endocrine

Denies:

• Excessive hunger

• Excessive thirst

• History of blood transfusion

She reports having a previous HIV test during blood donation.

Psychiatric

Denies:

• Depression

• Anxiety

• Previous psychiatric hospitalization

Physical Examination Findings

Vital Signs

• Weight: 170 lbs

• Height: 5 ft 5 in

• BMI: Not provided

• Temperature: 37.1°C

• Blood Pressure: 120/70 mmHg

• Pulse: 68 beats/minute

• Respiratory Rate: 20 breaths/minute

General Appearance

The patient appears healthy and is alert, cooperative, and able to answer questions appropriately. No obvious abnormalities are observed.

Skin Examination

Skin is dry, intact, and free of bruising or lesions.

HEENT Examination

• Head: Normocephalic and non-tender

• Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA)

• Ears: Symmetrical and patent bilaterally

• Nose: Nares patent

• Oral cavity: Teeth intact without dental caries

Cardiovascular Examination

• Regular rate and rhythm

• Normal S1 and S2 heart sounds

• No murmurs or additional heart sounds

• No peripheral edema

Respiratory Examination

• Symmetrical chest expansion

• Clear lung sounds bilaterally

• Even and unlabored breathing

Gastrointestinal Examination

The abdomen is soft and non-tender with bowel sounds present in all four quadrants. The patient reports lower abdominal cramping only during menstruation.

Breast Examination

Breasts are non-tender with no masses, skin changes, or nipple discharge noted.

Genitourinary Examination

Findings include:

• Normal vulva without lesions or masses

• Normal vaginal appearance without lesions

• Normal cervix without discharge or abnormalities

• Anteverted, non-tender uterus

• Non-distended, non-tender bladder

• Normal rectal tone

A Pap examination was performed using a speculum.

Musculoskeletal Examination

The patient demonstrates full range of motion in all extremities without pain or stiffness.

Neurological Examination

• Clear speech

• Steady gait

• Normal posture

• No neurological deficits observed

Psychiatric Examination

The patient is alert and oriented to person, place, and time. Appearance, speech, and behavior are appropriate.

Diagnostic Testing and Laboratory Evaluation

The following tests are recommended to evaluate abnormal uterine bleeding and identify possible hormonal, metabolic, or structural causes:

• Complete Blood Count (CBC): Evaluates for infection and possible anemia related to abnormal bleeding.

• Comprehensive Metabolic Panel (CMP): Assesses electrolyte balance and metabolic function.

• Ferritin Level: Evaluates iron stores and possible iron deficiency.

• Pregnancy Test: Rules out pregnancy-related causes such as miscarriage or ectopic pregnancy.

• Thyroid-Stimulating Hormone (TSH): Evaluates thyroid function, which can affect menstrual cycles.

• Prolactin Level: Assesses pituitary gland function and hormonal abnormalities.

• Total Testosterone: Evaluates androgen levels associated with conditions such as PCOS.

Assessment and Differential Diagnosis

Primary Diagnosis: Polycystic Ovary Syndrome (PCOS)

PCOS is the leading suspected diagnosis due to the patient’s irregular menstrual pattern after stopping birth control, fatigue, thinning hair, and possible hormonal imbalance.

PCOS is a common endocrine disorder involving increased androgen production, which may result in:

• Irregular menstrual cycles

• Abnormal vaginal bleeding

• Ovulatory dysfunction

• Difficulty with fertility

• Increased risk of metabolic conditions, including diabetes

Endometriosis

Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus. It may involve the ovaries, fallopian tubes, and pelvic lining.

Possible symptoms include:

• Pelvic pain

• Severe menstrual cramping

• Abnormal bleeding

• Fertility concerns

Uterine Fibroids

Uterine fibroids are noncancerous growths that develop within the uterus. They may contribute to:

• Abnormal uterine bleeding

• Pelvic pressure

• Fertility problems

Treatment and Management Plan

Medication Management

Recommended treatment options include:

• Restarting hormonal birth control for at least three months to help regulate menstrual cycles and hormone levels.

• Considering androgen-blocking medication to reduce elevated androgen effects associated with PCOS.

Treatment decisions should be individualized based on laboratory findings, patient preferences, and risk factors.

Lifestyle Recommendations

The patient should be educated on lifestyle modifications that support hormonal and metabolic health, including:

• Maintaining a balanced diet

• Increasing daily physical activity

• Supporting healthy weight management

• Monitoring blood glucose levels due to family history and increased PCOS-related diabetes risk

Imaging Evaluation

A pelvic ultrasound is recommended to evaluate for:

• Polycystic ovarian changes

• Uterine abnormalities

• Structural causes of abnormal bleeding

Patient Education

The patient should receive education regarding PCOS and associated health risks, including:

• Type 2 diabetes

• Cardiovascular disease

• Infertility concerns

• Long-term hormonal effects

Education should emphasize the importance of follow-up care, lifestyle management, and routine health screenings.

Cultural Considerations

Healthcare providers should consider the patient’s personal beliefs and comfort level regarding hormonal contraception and medication use. Treatment decisions should involve shared decision-making and respect the patient’s values.

Preventive Care Recommendations

Recommended preventive screenings include:

• Cervical cancer screening (Pap testing according to guidelines)

• Breast cancer screening when appropriate based on age and risk factors

Referral and Follow-Up

Referral:

• Refer to an OB/GYN specialist for further evaluation and management.

Follow-Up:

• Schedule follow-up appointment in approximately 12 weeks to evaluate treatment response, review laboratory results, and adjust management as needed.

References

Cleveland Clinic. (2023). Polycystic ovary syndrome (PCOS). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8316-polycystic-ovary-syndrome-pcos

James, A. H. (2016). Heavy menstrual bleeding: Work-up and management. Hematology: American Society of Hematology Education Program, 2016(1), 236–242. https://doi.org/10.1182/asheducation-2016.1.236

NU576 Unit 5 Journal

Johns Hopkins Medicine. (n.d.). Uterine fibroids. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/uterine-fibroids

Mayo Clinic. (2018, July 24). Endometriosis: Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656