Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction. Abnormal Uterine Bleeding
General Patient Information
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills. Abnormal Uterine Bleeding
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days during periods for the past one year.
Quality/Characteristic: Patient reported heavy prolonged menstrual pain; severe, sharp lower abdominal/pelvic cramping/pain, and blood clots during periods.
Aggravating Factors: Monthly periods as stated by the patient.
Relieving/Alleviating Factors: Patient stated that ibuprofen pain medication, heating pad, and/or warm sitz bath help the pain/cramping. Abnormal Uterine Bleeding
Severity: The severity of the pain/cramping on a pain scale is 10/10 reported by the patient.
Treatments/Therapies: Patient stated that she had not undergone any treatment for the reported problems.
Last Menstrual Period: The last menstrual period reported by patient was 7/5/2016.
Sexual Activity Status: Patient reported being sexually active.
Barrier Prevention: Patient stated she uses natural barrier methods.
Sexual Preference: Patient sexual preference is monogamous/heterogeneous relationship.
Satisfaction with Sexual Activity: Patient reported that she is sexually satisfied with her partner.
Contraception Method: Patient denied using any contraception method. Abnormal Uterine Bleeding
Past medical History (PMH): Anemia and C-section. Patient was delivered full term through vaginal delivery without complications. The birth weight was 8 pounds 10 oz.
Psychological/Mental Health: Patient denied depression, mood swings, anxiety, or mental health problem.
Medications: RG reported that she takes over the counter Motrin 200-400 mg orally every 4-6 hours as needed for pain and cramping.
Allergies: Patient reported no known allergies (NKA).
Past Surgical/Hospitalization History: Patient reported history of C-section twice, and she was hospitalized for 3 days post the C-sections.
Preventive Screening: Patient reported that she had flu shot on 11/20/2015; last mammogram was 2/12/2015 and mammogram was normal; Pap smear was on 2/20/2015, which was also normal; patient also reported that she was up to date with her childhood immunization, but denied pneumococcal vaccination. Abnormal Uterine Bleeding
Family History: Both father and mother have history of diabetes mellitus type 2 and hypertension. Both parents are still living, and two siblings are still living and well.
Gynecological History: Patient is multipara with 2 pregnancy resulting in two viable offsprings. Patient had her first child at the age of 33 years. Menarche at age 13; periods last between 5 to 7 days. Patient reported heavy prolonged menstrual bleeding with severe cramping; sharp pelvic pain during menstruation; and bleeding between periods for the past one year. Denied vaginal discharge or sexually transmitted infection/disease.
Obstetric History: Gravida 2, Para 2, term 2, preterm 0, spontaneous abortion 0, and living 2 (G2T2P2A0L2). Gravida 1: Delivered at 39 weeks by C-section on 4/20/08 male; Gravida 2: Delivered at 40 weeks by C-section on 2/18/15 female. Patient denied therapeutic abortion (TAB) or spontaneous abortion (SAB); Patient denied preterm or low birth weight baby with no delivery complications. Patient also denied having sexual transmitted disease. Abnormal Uterine Bleeding
Personal/Social History: Patient is married with 2 children, and lives at home with the husband. Patient is a college graduate; works outside the house as a nurse at a nearby hospital. Patient’s husband works for a computer company. Patient family is a middle income family. Also, patient denied any physical or psychological abuse. Patient denied being exposed to any environmental or occupational health hazards. Patient also denied alcohol consumption, tobacco, or recreational drug use. Patient denied participating in any exercise or physical activity because she is tired after work, and prefers to rest. Patient reported that she eats healthy; she eats low fat, low carbohydrate meals, and she eats fruits and vegetable at least 3 to 4 times a week. Patient stated
that she sleeps well at night, and she usually goes to bed at 9 pm and wakes up at 6 am. Patient drinks a cup of coffee occasional, especially when she is at work to be awake.
Review of System (ROS)
General: RG admitted fatigue and weakness; denied fever /chills; and no weight loss.
Head and Neck: Patient denied headache or dizziness. Patient also denied lumps, neck injury, pain/tenderness or jugular vein distention.
Chest: Patient denied chest pain, cough or shortness of breath. Abnormal Uterine Bleeding
Heart: RG denied irregular heartbeats, heart attack, or heart murmur.
Breasts: Patient denied nipple discharge, tenderness or swelling.
Gastrointestinal: Patient admitted lower abdominal pain, pressure, and bloating; denied constipation, nausea, vomiting, and diarrhea.
Genitourinary: RG denied urinary tract infection, urinary frequency or burning on urination.
Genital: Patient admitted heavy prolonged menstrual bleeding with severe cramping for one year. Patient admitted sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, and blood clots during periods. Patient denied vaginal discharge.
Musculoskeletal: RG denied varicosities or extremities problem.
Psychiatric: RG denied depression, anxiety, or any psychiatric problems.
Neurological: Patient admitted fatigue and weakness; denied confusion, seizures, or tingling.
Hematologic: Patient admitted history of anemia; denied blood transfusion or easily bruise or bleeding.
General exam: Patient appeared well developed and pleasant with good hygiene. Patient also appeared pale and weak. Vital signs: Blood pressure 118/76, heart rate 80, respiration 18,
temperature 98.8, pulse ox 100% on room air. Weight 78.2 kg, height 67 inches, and body mass index (BMI) 27.
HEENT: The head is normaceplalic, atraumatic. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Tympanic membrane is gray bilaterally. Oral mucosa is dry. Oropharynx is clear. Nares are patient, no nasal or septal deviation noted. No pharyngeal erythema. Abnormal Uterine Bleeding
Neck: Noted to be supple without jugular vein distention (JVD), thyromegaly or lymphadenopathy.
Lungs: Noted to be clear to auscultation throughout the lobes; no wheezes or rhonchi noted.
Cardiovascular: Regular rate and rhythm on auscultation, S1 S2 present without murmurs. Palpable pulses noted without peripheral edema.
Gastrointestinal: Bowel sounds are active in all quadrant. Abdomen is soft and tender on palpation.
Breast: The size of the breasts, areolas, and nipples are round and symmetrical with no discoloration, rash, lesions, dimpling, or retraction bilaterally; no masses, lumps, or tenderness noted on palpation bilaterally; and axillary lymph nodes non-palpable Abnormal Uterine Bleeding
Also check: Comprehensive Integrated Psychiatric Assessment