Posted: May 1st, 2025

responses.

PLEASE RESPOND TO THE TWO POSTS WITH 2 PARAGRAPHS FOR EACH

POST 1

Donna is 35-year-old African American female who comes to the cliniccomplaining of pelvic pain that started as intermittent, but now is almostconstant. She also complains of irregular vaginal bleeding/spotting that hasoccurred in between her monthly menses for the last six months. She has nofamily history of breast or ovarian cancer. Her vital signs (VS) and BMI are allwithin normal limits (WNL), but upon physical examination, you palpate a firm,raised area on her uterus. You note no cervical motion tenderness (CMT), noadnexal tenderness (AT), and no other abnormalities. She is G2 P2 with bothnormal spontaneous vaginal deliveries (NSVD) 10 and 8 years ago.

Subjective:• Chief Complaint (CC): Pelvic pain and irregular vaginal bleeding.• History of Present Illness (HPI): Donna, a 35-year-old African American female, presents with pelvic pain that has progressed from intermittent to constant, along with irregular vaginal bleeding/spotting for the past six months. •

Medications:

No current medications.• Allergies:No known drug allergies.• Last Menstrual Period (LMP): Two weeks ago.• Gyn/OB history: G2P2 with normal spontaneous vaginal deliveries 10 and 8 years ago.• Past Medical History (PMH): No significant past medical history.•

Family History:

Denies family history of breast, uterine, cervical or ovarian cancer.•

Social History:

Non-smoker, occasional alcohol use.

Review of Systems (ROS):General:• Denies weight loss or fatigue reported.• No fever, chills, or night sweats reported.Cardiovascular
:• Denies chest pain, palpitations, or edema.• No history of heart murmurs or irregular heartbeats reported.Respiratory:• Denies cough, shortness of breath, or wheezing.• No history of asthma or chronic obstructive pulmonary disease (COPD) reported.Gastrointestinal:• Denies abdominal pain, nausea, vomiting, or changes in bowel habits.• No history of gastroesophageal reflux disease (GERD) or peptic ulcers reported.Genitourinary/

Gynecological
:

• Reports regular menstrual cycles but complains of irregular vaginal bleeding/spotting between menses.• Reports pelvic pain.• Denies dysuria, hematuria, or urinary frequency.• No history of sexually transmitted infections (STIs) reported.Breast:• Reports no abnormalities. • Denies breast pain, nipple discharge (except during lactation), changes in breast size or shape, nipple inversion, or previous breast surgeries/injuries.Integumentary:• No history of skin lesions, rashes, or itching reported.• Denies changes in moles or pigmented areas.• No history of excessive bruising, skin infections, or hair loss reported.

a. In addition to the information provided in the scenario, it would be relevant to inquire about the quality and timing of pelvic pain, any exacerbating or alleviating factors, associated urinary or bowel symptoms, and recent changes in menstrual patterns or bleeding (American College of Obstetricians and Gynecologists [ACOG], 2020). b. It’s important to ask about the patient’s medical history, including any previous gynecological conditions or surgeries, history of sexually transmitted infections (STIs), contraceptive use, and chronic medical conditions such as diabetes or hypertension (ACOG, 2020). c. Social history questions should include inquiries about sexual activity and practices, smoking history, alcohol or drug use, and recent life stressors that may impact the patient’s health and well-being (ACOG, 2020).d. Family history questions should focus on reproductive cancers (e.g., breast, ovarian, uterine), genetic conditions related to gynecological health, and any family history of pelvic pain or menstrual irregularities (ACOG, 2020).

Objective:• General: Well-nourished, no acute distress.• Vital Signs: BP 120/80 mmHg, HR 72 bpm, RR 16/min, Temp 98.6°F.• Pelvic Exam: Firm, raised area palpated on the uterus. No cervical motion tenderness (CMT) or adnexal tenderness (AT).• Breast Exam: Right breast normal. Left breast normal.

a. A detailed focused physical assessment would involve inspection and palpation of the abdomen and pelvic area, including examination of the uterus, ovaries, and cervix. A speculum exam and bimanual pelvic exam would be performed to assess for abnormalities, tenderness, or masses (ACOG, 2020). b. Diagnostic tests would include a pelvic ultrasound to visualize pelvic organs and assess for structural abnormalities like fibroids or ovarian cysts. Additionally, a Pap smear may be done for cervical cancer screening, and blood tests such as a complete blood count (CBC) and hormone levels (e.g., estrogen, progesterone) may be ordered (ACOG, 2020).

Physical Assessment:

General Appearance: Donna appears her stated age and ethnicity, well-nourished, and in no acute distress. She is cooperative and alert during the examination.Vital Signs:• Blood Pressure: 120/80 mmHg• Heart Rate: 72 bpm• Respiratory Rate: 16/min• Temperature: 98.6°F• BMI: Within normal limitsHead and Neck:• Inspection: No visible abnormalities or masses on the scalp, face, or neck.• Palpation: No tenderness or lymphadenopathy in cervical lymph nodes.Breast Examination:• Inspection: No visible asymmetry, redness, dimpling, or skin changes overlying the breasts.• Palpation:• Right Breast: No palpable masses or abnormalities noted.• Left Breast: No palpable masses or abnormalities noted.Cardiovascular:• Heart sounds are regular with no murmurs, rubs, or gallops.• No peripheral edema noted.Respiratory:• Lung fields clear to auscultation bilaterally without wheezes, rales, or rhonchi.Abdominal
Examination:• Inspection: Abdomen is soft, non-tender, and non-distended.• Palpation: A firm, raised area palpated on the uterus indicating a possible uterine mass. No other masses or tenderness noted.Pelvic Examination:• Inspection: No external genital abnormalities or lesions.• Speculum Examination: Normal vaginal walls without discharge or lesions.• Bimanual Examination: Uterus is palpated to have a firm, raised area. No cervical motion tenderness (CMT) or adnexal tenderness (AT) noted. No adnexal masses palpable.Skin
Examination:• No rashes, lesions, or discoloration noted on the skin.

Presumptive Diagnosis: Uterine fibroids – ICD-10 Code: D25.9 (Leiomyoma of uterus, unspecified): Fibroids are occasionally discovered by medical providers when doing a standard gynecological exam. Using one hand to insert two fingers into the vagina and the other to gently press on your abdomen, the medical provider measures the size of the uterus during this exam. The uterus may feel larger than usual or may not have the proper shape if you have fibroids. The size of the fibroids does not seem to be related to the severity of symptoms, so even small fibroids may cause considerable symptoms and heavy periods. If there are symptoms but the health care provider cannot feel any fibroids during a manual examination, other types of imaging technology—machines that create a picture of the inside of the body—are used to diagnose uterine fibroids (NIH, 2021).

Differential Diagnoses: a. Endometriosis – ICD-10 Code: N80.9 (Endometriosis, unspecified): Endometriosis is a common gynecological condition characterized by the presence of endometrial-like tissue outside the uterus, leading to symptoms such as pelvic pain, irregular bleeding, and infertility (Mayo Clinic Staff, 2021).

b. Ovarian cysts – ICD-10 Code: N83.20 (Unspecified ovarian cysts): Ovarian cysts are fluid-filled sacs that can develop on the ovaries, and while they often resolve on their own without causing symptoms, larger or persistent cysts can lead to pelvic pain, bloating, and changes in menstrual patterns (Mayo Clinic Staff, 2021).

c. Pelvic inflammatory disease (PID) – ICD-10 Code: N70.90 (Pelvic inflammatory disease, unspecified): PID is an infection of the female reproductive organs, often caused by sexually transmitted infections (STIs) such as chlamydia or gonorrhea. It can lead to pelvic pain, abnormal vaginal discharge, and fertility issues if left untreated (Mayo Clinic Staff, 2021).

d. Cervical dysplasia – ICD-10 Code: N87.9 (Dysplasia of cervix uteri, unspecified): Cervical dysplasia refers to abnormal cell changes in the cervix, often detected during routine Pap smears. It is commonly caused by human papillomavirus (HPV) infection and can progress to cervical cancer if not monitored or treated (Mayo Clinic Staff, 2021).

Assessment/Diagnosis:a. The presumptive diagnosis is likely uterine fibroids based on the patient’s age, symptoms, and physical findings. A pelvic ultrasound would confirm the diagnosis by visualizing fibroids in the uterus (ACOG, 2020).b. Differential diagnoses to consider may include endometriosis, ovarian cysts, pelvic inflammatory disease (PID), or cervical dysplasia, which may require additional testing or imaging for confirmation (ACOG, 2020).

Plan:1. Diagnostic Tests: Order pelvic ultrasound, Pap smear, CBC, and hormone levels to confirm diagnosis and rule out other conditions (Committee on Practice Bulletins—Gynecology, 2012).

2. Referral: Refer to a gynecologist for further evaluation and management (Tricco, 2014).

3. Symptomatic Management: Prescribe NSAIDs for pain relief, and consider hormonal therapies for menstrual regulation if indicated (NICE, 2021).

4. Patient Education: Educate the patient on uterine fibroids, treatment options, and the importance of follow-up care (Mayo Clinic, 2021).

5. Follow-Up: Schedule a follow-up appointment in two weeks to review test results and adjust the treatment plan if needed (CDC, 2023).

a. Management involves addressing symptoms and potential complications of uterine fibroids. Treatment options may include medications like NSAIDs for pain relief or hormonal therapies for menstrual regulation (ACOG, 2020). b. Treatment guidelines consider factors such as the patient’s age, reproductive plans, and symptom severity. Side effects of medications should be discussed, such as gastrointestinal upset with NSAIDs or hormonal side effects with therapy (ACOG, 2020). c. Patient education should cover the diagnosis, treatment options, potential medication side effects, and lifestyle modifications (e.g., exercise, stress management) (ACOG, 2020). d. Follow-up care involves monitoring symptoms, medication efficacy, and potential changes in the condition. Follow-up visits may include repeat imaging or blood tests as needed (ACOG, 2020). e. Complications of untreated uterine fibroids may include worsening symptoms (e.g., increased bleeding, pain), anemia from heavy bleeding, and potential impact on fertility or pregnancy outcomes (ACOG, 2020).

POST 2

Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is sometimes so severe that she fainted. She states that defecation can cause severe pain and she therefore frequently becomes constipated. She often must miss work when experiencing the severe pain. Her periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is 23.9 and her VS are all WNL. She is G0 P0.

SUBJECTIVE:

Demographic Data: K.N; 19-year-old Hispanic female

Chief Complaint: New patient K.N., 19-year-old Hispanic female, G0P0; in office today with complain of been having severe menstrual pain that is severe prior to start of menstrual and last for the first 2 days of her menstrual period. She describes the pain can get so bad that she even fainted, with pain upon defecation which also with frequent constipation. She even had to miss work due to the severe pain and heavy flows that would last up to 7 days.

HPI: A 19-year-old female, G0P0, Kelly, presents to the office today with complain of having sever menstrual pain that is so sever prior to start of her cycle and last for the first 2 days of the cycle. She reported that the pain was so severe that she even had syncopal episodes due to pain. As patient informed us that the pain was to the lower abdomen area, with pressure sensation and bad cramps episodes. This pain comes and goes all days from a few days before her menstrual period started to about 2 days after it started. The pain only happens with her menstrual period. Patient reported that she’s been having these painful episodes with her menstrual periods for the last 5 years. Her menstrual periods been off a few days and there as she noticed that its frequency was due to the increased level of stresses and as the stresses level increased, the pain was getting more severe. Her periods are heavy and last seven days with them being lighten last few days. Patient has never been pregnant in the past. She is G0P0, and she is not sexually active. But she been noticing pain upon defecation which also with frequent constipation, but denies any pain with urination. Patient denies any history of any work-up in the past for these painful menstrual periods as they’ve been relieved with Tylenol and Midol. She reported that these few days of her painful menstrual periods had caused her to miss work and that she even had syncopal episodes.

GYN Risk Factor History:

Age at Menarche: 11 years old

Last Menstrual Period: 5 days ago.

Age at Menopause: N/A

Use of OCP: Not currently; not sexually active

Pregnancy History: G0P0

Age at First Live Birth: NA

Age at Last Live Birth: NA

Length of Breastfeeding: NA

Use of Fertility Treatment: NA

Use of HRT: NA

Past Medical History:

Denies any medical history

Heavy menstrual period for the last 5 years with severe pain

Constipation at times with painful defecations

Syncopal episodes due to severe pain with menses but not been seen by any physician.

Past Surgical History:

Appendectomy at the age of 10

Tonsillectomy at the age of 8

Wisdom teeth removed

Family History:

Mother: uterine fibroids with his of Uterine Artery Embolization at the age of 42; Heavy menstrual periods prior to UAE; HTN; DM; G4P2, with 2 miscarriages;

Father: TIAs, HTN, DM, Hypercholesterolemia

Maternal Grandparents: unknown as they passed away young

Paternal Grandparents: healthy; no medical history

Social History:

Smoking: denies

Alcohol: denies

Illicit drugs: denies

Social Determinants of Health:

Financial Resource Strain: none

Food Insecurity: none

Transportation Needs: none

Housing Stability: none

Allergies: no known drug allergies

Medications:

Tylenol 500mg orally, 4 times a day as needed for menstrual cramps/headache

Midol take 2 tables every 8 hours as needed for menstrual cramps/headache

MVI, 1 tablet daily

ROS:

GENERAL: No weight loss or gain, fatigue, problems with appetite or wellbeing.

DERM: No rashes, unusual moles, or other skin problems.

ENDOCRINE: The patient denies polyuria, polydipsia, excessive fatigue, significant weight loss or gain, problems with appetite, unusual hair growth.

BREASTS: The patient denies any breast lumps, nipple discharge or changes in the skin in the breast area.

RESPIRATORY: Denies Chronic cough, sputum production, hemoptysis, asthma, wheezing, sleep apnea.

CARDIAC: The patient denies palpitations, chest pain, pain in the arm or neck on exertion, shortness of breath, dyspnea on exertion or syncope.

GI: Denies appetite disturbance, dysphagia, nausea, vomiting, rectal bleeding. Positive for painful defecations along with her menstrual cycles; Positive for constipation with painful defecation

GU: The patient denies frequency, dysuria, urgency, nocturia or hematuria.

GYN: G0P0; The patient denies chronic pelvic pain, genital lesions, abnormal vaginal discharge. Denies sexual activity; severe cyclic pelvic pain for a few days; denies any vulvar pruritus or burning; Heavy menstrual periods for first few days and lighter last 3 days (duration of 7 days each cycle).

MUSCULOSKELETAL: The patient denies excessive muscle aches, chronic or radicular back pain, joint stiffness, arthralgia, or weakness.

NEURO: The patient denies seizure, memory loss, tingling/numbness, blurred vision, syncope, difficulty with gait or balance, unusual tremor, difficulty with speech or coordination.

PSYCH: No problems with anxiety or depression.

OBJECTIVE:

Vital:

BP 148/68 (BP Location: Right arm, Patient Position: Sitting)

Pulse 75

Temp 36.8 °C (98.2 °F) (Tympanic)

Resp 14

Ht 5’10” Wt 63.1 kg (166 lb 3.2 oz)

BMI 23.9 kg/m² (Healthy Range)

Physical Exam:

Constitutional
:

Appearance: Normal appearance. Alert. Oriented. No acute distress. Pleasant and Cooperative. HENT
:

Head: Normocephalic and atraumatic.Cardiovascular:

Rate and Rhythm: Normal rate. Pulses: Normal pulses.Pulmonary
:

Effort: Pulmonary effort is normal.

Breasts
:

Exam was performed in the sitting position and supine position. Chaperone present.

Symmetrical bilateral breasts noted; no changes in color noted; no skin/nipple dimpling nor retractions; no spontaneous nipple discharges; No masses. No palpable axillary lymphadenopathy.

Abdominal: General: Abdomen is flat. Bowel sounds are normal. Palpations: Abdomen is soft. Some tenderness noted upon palpation

Gynecological:

External genitalia appear normal; normal hair appearance; No clitoromegaly; no superficial nor subcutaneous lesions noted.

The Bartholin’s gland openings are located within normal positions; non-palpable Skene’s glands

No lesions noted within the vagina and cervix; the vagina is also absence of rugae.

Moderate amount of bleeding noted since patient is on the last 2 days of her cycle.

Musculoskeletal
:

General: Normal range of motion. Cervical back: Normal range of motion.

Lymphadenopathy
:

Cervical: No cervical adenopathy.Skin:

General: Skin is warm and dry.Neurological
:

General: No focal deficit present. Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.Psychiatric
: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal.

ASSESSMENT/DIAGNOSIS:

Working Diagnosis:

ICD 10: N80.9 Endometriosis

This is my final diagnosis as patient has severe pain, that associated with menstrual periods. She also has pain with defecations along with constipation around her menstrual periods. As patient also reported heavy bleeding for the first few days of her cycle.

Differential Diagnosis:

ICD 10: N83.20: Ovarian cysts, unspecified

ICD 10: N94.0: Mittelschmerz: this is as refer to as pain due to ovulation; It occurs before menstruation and could last minutes up to 2 days after start of menstruation. These pain episodes are light. Therefore, this is not a working diagnosis since patient has severe pain.

PLAN:

Labs: CBC, CMP, Cervical cultures; urine culture

Images/Procedures:

• Transvaginal ultrasonography to r/o cysts and mases

Interventions:

• Surgery: minimally invasive procedures can remove endometriosis tissue, cysts, and adhesions.
• Pharmaceutical Therapy:1st line therapy:COC pills in combination with NSAIDsMedroxyprogesterone acetate (MPA) 150 mg IM every 3 monthsIf pain persists after 3 months on COCs and NSAIDs:Gn-RH agonist empiric therapy for 3 monthsLupron 3.75 mg IM monthlyNafarelin (Synarel) nasal spray twice dailyDanazol 600-800 mg daily for up to 6 monthsLevonorgestrel IUD: to reduce in menorrhagia and dysmenorrhea symptoms.
• Teaching:Treatment goals include prevention of disease progression, alleviation of pain, and establishment or restoration of fertility.Treatment options: Observation alone, medical therapy or pharmacological therapy, referral or consultation for laparoscopic therapy including laser vaporization and removal of adhesions.Continuation, or recurrence of pelvic pain, may necessitate assisting the patient to manage her chronic pelvic pain and dysmenorrhea with NSAIDs and/or other non-narcotic chronic pain therapies, such as visualization and biofeedback.Hysterectomy and bilateral salpingo-oophorectomy are the only definitive cures for women who do not wish to conserve their reproductive capacity. They should be considered only as a last resort after failed conservative treatment.

Follow-up:

• Patient must return monthly while receiving Gn-RH agonist or danazol therapies to assess for symptom relief and side-effect profile.
• Patient with known endometriosis and a desire to conceive should be referred to a clinician specializing in infertility.

Health Maintenance:

• The workup, evaluation, and medications for endometriosis are expensive. Refer the client to a gynecologist for initial management.
• A prudent approach is recommended with a conservative treatment option; evaluate the results before trying another option.
• Refer the patient for a surgical consultation for definitive diagnosis as this endometriosis can be confirmed via visualization by laparoscopy.