Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain

Dayna
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 has 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
CC: severe dysmenorrhea, heavy periods, painful defecation, symptoms interfere with life style
HPI: 19 y/o F, G0P0 presents to clinic today with complains of menstrual pain and heavy menstrual bleeding. Patient states that pain is usually worse just prior to and during the first two days of her menses. Patient describes pain as severe, causing patient to faint and often causing her to miss work. Patient reports periods lasting seven days with a tapering of the bleeding from days 3 to 7. Patient also mentions that defecation can cause severe pain and she therefore frequently becomes constipated.
What other relevant questions should you ask regarding the HPI?
When did you start experiencing pain? Was onset sudden or gradual?
Where does pain occur? Is it localized or diffused? Lower abdomen, lower back, inner thighs?
What does the pain feel like? Is it sharp, dull, burning, aching, cramping etc.,?
Is there anything which makes this pain better or worse (compress, hot shower, physical exercise)?
Does this pain in your breast radiate anywhere in your body?
Would you say that your pain is getting progressively worse over time?
Do you experience pain between menstrual periods?
How severe is the pain on the scale from 0 to 10?
Did you attempt to take any medications to help relieve pain? Was it successful?
Did you always heavy periods from onset of menses?
Do you have an bleeding between periods?
Are you sexually active? Is your intercourse painful?
How frequent are your BM?
Did you notice any blood in your stool?
When did you start experiencing painful defecation and constipation?
Gyn/OB history:
G0P0
Any chance you can be pregnant?
How old were you when you started your period?
Heavy menses that last seven days with a tapering of the bleeding from days 3 to 7
Have you noticed any changes in your menstrual cycle, such as irregular periods or changes in flow?
Do you experience blood clots during menstruation?
What method of contraception do you use? Do you have IUD? Any hx of STIs?
Have you been tried to conceive without success?
Any history of pelvic inflammatory disease, endometriosis, or other gynecological conditions?
What other medical history questions should you ask?
Do you take any new medications, including OTC or supplements?
Do you take oral birth control pills? If so, does it provide any pain control/relief?
Do you have allergies?
Any chronic medical conditions, such as diabetes or thyroid disorders?
Have you been treated for dysmenorrhea in the past?
Do you have any other medical issues?
Any past surgeries, including surgeries to the reproductive system?
What other family history questions should you ask?
Are there any family members with a history of gynecological disorders, like endometriosis, PID, infertility?
Any family history of dysmenorrhea or heavy prolonged menses?
Any history of cancer in the family, including cancer of reproductive organs?
Anu hx of autoimmune disorders in your family?
Any history of early menses onset in your family?
What other social history questions should you ask?
Social Hx:
Do you drink, smoke, use drugs?
How much of a physical activity you get daily?
What do you do for work?
What does your diet look like?
ROS
General: : Any fever fever, chills, malaise? Reports fatigue right before and during menses.
HEENT: Denies changes in vision and hearing, sore throat, and dysphagia
Cardiovascular: Denies chest pain and palpitations
Respiratory: Denies shortness of breath or cough
Gastrointestinal: Reports pain with defecation and constipation. Any nausea, vomiting, diarrhea, associated with menstrual pain?
Genitourinary: Any frequency or urgency or pain with urination? Reports lower abdomen/lower back intense cramping, heavy menstrual bleeding
Integumentary: Denies rash, pruritus, erythema
Breast: Do you notice any breast changes right before and during menstruation. Denies breast pain, skin changes, nipple discharge.
Musculoskeletal: Denies myalgia, joint pain
Neurological: Denies headache, dizziness, weakness. Reports syncope s/t pain
Psychological: Denies depression, anxiety, or suicidal thoughts. Reports insomnia s/t pain and acute distress around periods due to interruption of daily routine and responsibilities
Objective Data
Write a detailed focused physical assessment on this patient.
VS: WNL
BMI – 23.9
POCT:
Pregnancy test – negative
General: A&O x 4, normal weight, no signs of acute distress, cooperative and answering questions appropriately
Respiratory: Clear breath sounds to auscultation bilaterally, no use of accessory muscles, respirations within normal range
Cardiovascular: Regular rate and rhythm, SI and S2 auscultated, no murmur, no JVD.
Integumentary: Skin warm and dry with no rashes, no lesions, or erythema
Gastrointestinal: BS present x4 quadrant, no abdominal guarding with palpation
Genitourinary: Palpating abdomen to assess for tenderness or masses
Pelvic exam:
• External genitalia: Normally developed genitalia
• Vagina: Visually inspecting for discharge or bleeding, lesions
• Adnexa: palpating for tenderness or masses, ovaries
• Uterus and cervix : bimanual exam for size to r/u enlargement, shape, position to r/u irregular-shaped mobile uterus, bogginess and restricted motion of the uterus, nodules in the posterior fornix
• Rectum: visualizing and digital exam for hemorrhoids or any other abnormalities
Psychological: Cooperative, appropriate mood and affect
Assessment/ Diagnosis
What is your presumptive diagnosis? Why?
Secondary dysmenorrhea possibly due to endometriosis N94.5, N80.0
Any other diagnosis or differential diagnosis you would like to add?
Differential Diagnosis:
Primary dysmenorrhea N94.4
Begins early in the reproductive years, starts before or at the beginning of menstruation. The pain typically lasts 8 to 72 hours and is most severe on the first day of menstruation. Can be accompanied by nausea, vomiting, diarrhea, and fatigue. Nulliparity and high BMI are major risk factors (Alexander et al., 2023). This pattern describes Kelly’s menstruation, but the severity of pain accompanied by heavy HMB and pain with defecation makes me consider secondary nature of it and look into other possible causes. Additionally, Kelly’s BMI in a healthy range.
Other possible causes include:
Pelvic inflammatory disease (PID) N73.9, Adenomyosis N80.03, Ovarian cyst N83.2, Uterine fibroids (leiomyoma) D25
Secondary dysmenorrhea is often caused by endometriosis, but other causes include adenomyosis, leiomyomas, ovarian cysts, and PID, and is often accompanied by AUB/HMB (Alexander et al., 2023). Kelly’s symptoms of severe menstrual pain accompanied by heavy periods, are consistent with description of secondary dysmenorrhea. The possibility of endometriosis should be considered due to the severity of symptoms and the presence of pain with defecation and constipation.
Plan
How will you manage this patient? What treatment or medication would you prescribe and why?
Diagnostics
Transvaginal ultrasound
Typically the initial imaging study. Allows for routine pelvic imaging and evaluation of the posterior compartment, observation of the relative positioning of the uterus and ovaries. Expected findings consistent with pelvic endometriosis include ovarian cysts, nodules of the rectovaginal septum, and bladder nodules (Schenken, 2024).
CBC – to evaluate for anemia due to hx of HMB
Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s)
The surgical diagnosis of endometriosis has been the gold standard, particularly before initiating treatments with significant negative side effects such as gonadotropin-releasing hormone agonists or antagonists. However, presumptive clinical diagnosis based on symptoms, physical examination, and imaging is beneficial especially for starting low-risk interventions such as hormonal contraceptives, as presumptive diagnosis is less invasive, and reduces treatment delay (Schenken, 2024).
Start Acetaminophen or NSAIDs, such as ibuprofen, naproxen, or celecoxib, 1 to 2 days before the anticipation of the onset of menses. Stomach ulcers or gastrointestinal bleeding are serious side effects if taken for a long time
Start combined estrogen-progestin hormonal contraceptives for 6-12 months. Side effects include HTN, bloating, breakthrough bleeding, nausea, breast tenderness, blood clots.
If Kelly does not respond adequately to NSAID/COCs therapy, surgical diagnosis with histologic evaluation of a biopsied tissue via laparoscopy is indicated, which will allow for definitive diagnosis and treatment (growth, scar tissue, or adhesions removal) at the same time (Schenken, 2024).
Referrals: none at this time
What patient education is important to include for this patient? (Consider including pharmacological, supplements, and non
pharmacological recommendations and education)
Education:
• Heating pads and warm baths can help relieve pain
• An anti-inflammatory diet consisting of mainly fruits, vegetables, whole grains, and foods rich in omega-3 fatty acids may be beneficial
• Limit caffeine and alcohol intake
• Walking, swimming, and biking can help reduce estrogen levels as well as inflammation.
• Endometriosis can make it more difficult to become pregnant due to development of scar tissue in the ovaries or fallopian tubes
Explain complications that can occur if patient does not comply with treatment regimen?
Endometriosis can cause infertility (30-50%). If endometrial tissue grows outside the uterus it can affect other organs, including bowel and bladder.
Health Maintenance
• Pap smear (every three years starting at age 23)
• STI screening every time a sexual history reveals new or persistent risk factors
• Annual physical with comprehensive blood work (yearly)
• Screening mammogram starting at age 45 (yearly)
What is the follow-up plan of care?
Follow up: in 6-8 weeks to assess treatment effectiveness

Samantha
Subjective
• Chief Complaint: pelvic pain and irregular bleeding
• History of Present Illness: Donna is 35-year-old African American female who comes to the clinic complaining of pelvic pain that started as intermittent, but now is almost constant. She also complains of irregular vaginal bleeding/spotting that has occurred in between her monthly menses for the last six months. She has no family history of breast or ovarian cancer.
What other relevant questions should you ask regarding the HPI?
• Do you experience pain during or after intercourse?
• Are you currently trying to conceive or having difficulty becoming pregnant?
• Have you had any pregnancy complications or uterine surgeries?
• When did the pain start, and how has it changed over time?
• Was there a triggering event (trauma, sexual activity, recent infections)?
• Is the pain localized or generalized? Does it radiate to the back, thighs, or elsewhere?
• How would you describe the pain (cramping, sharp, dull, burning)?
• On a scale of 0 to 10, how severe is the pain?
• Does the pain occur at specific times (during menstruation, ovulation, or intercourse)?
• Does anything make it better or worse (heat, rest, exercise, bowel movements, urination)?
• Are your menstrual cycles regular? How many days between periods?
• How long does your period last, and is it heavier than usual?
• How much bleeding occurs between periods (e.g., spotting or full flow)?
• Have you noticed clots?
• Is the pelvic pain worse during your period?
o Medications: What medications are you taking? Are you taking any medications or supplements, including over-the-counter or herbal remedies?
o Allergies/Immunizations: Any allergies? reports up to date with immunizations. Have you been vaccinated by HPV?
o LMP: LMP date?
o GYN/OB History: She is G2 P2 with both normal spontaneous vaginal deliveries (NSVD) 10 and 8 years ago.
o Have you been pregnant? If so, at what age was your first full-term pregnancy?
o Last PAP?,
o Last Mammogram? normal/abnormal result?
o Menarche: At what age?
o Are you on hormone replacement therapy, oral contraceptives, or other medications?
2. What other medical history questions should you ask?
• Have you experienced pelvic pain or irregular bleeding before this six-month period?
• Was the pain or bleeding similar or different to now?
• How are these symptoms affecting your daily activities, work, or quality of life?
• Have you ever been diagnosed with fibroids, ovarian cysts, endometriosis, or other uterine/ovarian conditions
• Have you ever had an abnormal Pap smear? If so, what follow-up was performed (colposcopy, biopsy)?
• Have you ever been diagnosed or treated for STIs such as chlamydia, gonorrhea, or HPV?
• Are your periods usually regular?
• Past Med. Hx (PMH): Tell me about your medical history. Have you had breast lumps, biopsies, or previous breast cancer?
• Surgical History: Tell me about your surgical history
3. What other social history questions should you ask?
• Social Hx:
o Do you smoke, drink alcohol, or use recreational Drugs?
o Are you in a relationship? Do you feel safe?
o Are you sleeping well? Have you been feeling stressed or overwhelmed recently?
o How much do you exercise a week?
o Who lives with you at home?
o Are you currently sexually active?
o What is your occupation?
o Are you up to date with other screenings, such as Pap smears or colonoscopies?
o Do you experience high levels of stress or anxiety?
o Do you have a support system to rely on?
What other family history questions should you ask?
• Family Hx: What is your family history? Does anyone in your family (maternal or paternal) have a history of breast, ovarian, or other cancers? Is there a history of heavy menstrual bleeding, easy bruising, or diagnosed bleeding disorders?
• Have any female relatives been diagnosed with uterine fibroids, endometriosis, or adenomyosis?
• Tell me about any other family hx
• Review of Systems (ROS):
o Constitutional: denies fever, night sweats, chills, fatigue, cold intolerance, weight gain, weight loss.
o Respiratory: denies dyspnea, cough
o Cardiovascular: denies chest pain or palpitations
o Gastrointestinal: denies abdominal pain, nausea, vomiting
o SKIN:Any changes in the skin of the breast, such as redness, dimpling, or thickening?
o GYN: reports pelvic pain that started as intermittent, but now is almost constant. Reports irregular vaginal bleeding/spotting that has occurred in between her monthly menses for the last six months
o Lymphatic: Any swelling or lumps in the armpit or neck?
o Psychiatric: denies anxiety, increased stress, depression, and suicidal ideation.
Objective
Write a detailed focused physical assessment on this patient
• Vital signs: BP, HR, Temp, Ht, Wt, BMI, SpO2, RR Her vital signs (VS) and BMI are all within normal limits
• GEN: Vital signs stable, in no acute distress. Alert, well developed, well nourished.
• RESP: Lungs clear to auscultation bilaterally, no abnormal sounds bilaterally, no use of accessory of muscles of respiration, nonlabored breathing, normal rate and rhythm, no shortness of breath, chest rise is equal and symmetric
• CV: S1, S2 without murmurs, rubs, or gallops appreciated.
• Abodmen/Pelvis: palpate a firm, raised area on her uterus. no cervical motion tenderness (CMT), no adnexal tenderness (AT), and no other abnormalities.
• INTEGUMENTARY: Skin was warm and intact. No rashes, masses or discoloration. No trauma.
• PSYCH: A&O x3 judgment/insight intact, NL mood/affect. Judgment and insight were within normal limits at the time of the visit.
Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
• POCT:
o UA: Identifies signs of urinary tract infection (UTI) or hematuria. UTIs, bladder infections, or other urinary tract issues causing pelvic discomfort.
Assessment (Diagnosis/ICD10 Code)
What is your diagnosis?
o Working Diagnosis:
• Leiomyomas (D25.9): Donna reports pelvic pain that started intermittently but is now constant. This is a common symptom of uterine fibroids as they can cause pressure or inflammation within the uterus. Donna’s complaint of irregular vaginal bleeding and spotting between her menses over the past 6 months is a typical symptom of uterine fibroids, especially if they are submucosal or intramural. Fibroids can cause menorrhagia (heavy menstrual bleeding) or bleeding outside of the regular cycle. The physical exam finding of a firm, raised area on the uterus is highly suggestive of fibroids. Larger fibroids are often palpable on bimanual examination. The absence of CMT may help differentiate fibroids from conditions like pelvic inflammatory disease (PID) or endometriosis, which would often present with tenderness or pain on cervical motion. Donna does not report symptoms such as fatigue, dizziness, or weakness, which would suggest anemia related to heavy menstrual bleeding. This is a pertinent negative, as anemia is a common complication of fibroids due to heavy menstrual bleeding.
• Adenomyosis (N80.0): Pertinent Positives: Dysmenorrhea, heavy menstrual bleeding (menorrhagia), chronic pelvic pain, enlarged and tender uterus, menstrual irregularities, infertility, pain with intercourse, and a history of uterine surgery.Pertinent Negatives: No menstrual pain, no heavy bleeding, normal-sized uterus, absence of chronic pelvic pain or dyspareunia, no history of uterine surgery, no infertility issues, and no evidence of ovarian cysts or back pain.

Excellent analysis! You’ve accurately identified the potential diagnoses and outlined a comprehensive approach to patient care.

Here are some additional considerations and potential diagnoses to explore:

Additional Questions for HPI:

• Sexual History:
  • Number of sexual partners
  • Use of protection (condoms)
  • History of sexually transmitted infections (STIs)
  • Painful intercourse (dyspareunia)

Additional Medical History Questions:

• Mental Health: History of depression, anxiety, or other mental health conditions
• Autoimmune Disorders: Family history of autoimmune diseases (e.g., lupus,