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Abnormal Uterine Bleeding

Abnormal Uterine Bleeding

Sample Answer 

Abnormal Uterine Bleeding

Subjective:

CC: “I have felt fatigued for the last 6 months, and I don’t understand why.”

HPI: The patient complained of fatigue over the last 6 months for no known reason. She also did not report any other symptoms, no change to her physical or emotional health, and no recent illness, including significant stress or depression. The patient reported regular monthly periods, with bleeding lasting 7 to 9 days. She typically uses super-absorbent tampons, changing them approximately every two hours in the first couple of days of her period. She also relies on pads for backup during her days of heavier flow. She has noticed that she sometimes passes quarter-sized clots. She reports no inter-menstrual or post-coital bleeding and is sexually active with only her husband

PMH:  Hypertension. The patient has had a tubal ligation and CS delivery of 3rd born child

Allergies: NKDA

FamHx: No family history of breast, ovarian, colon, or uterine/endometrial cancers and no history of abnormal Pap tests or positive screens for sexually transmitted infections.

Socx: The patient does not smoke and uses alcohol only in social situations.

Medication: 25 mg a day of hydrochlorothiazide and daily multivitamin

Objective:

General: The patient is a well-developed, obese white female in no apparent distress.

VS: BP: 138/87, Pulse: 78, Temp: 98.9°F, Ht: 5’6″; Wt: 267 pounds, BMI 43.09 kg/m2.

Abdominal: LLQ was difficult to palpate because of her abdominal girth, though the uterus did not appear to be enlarged, and there were no pelvic masses on palpitation.

Gynecological: No vulvar or vaginal lesions; a small amount of dark blood is present in the vault. There is no cervical motion tenderness or cervical lesions

Assessment of This Patient

Abnormal uterine bleeding is characterized by irregular uterine bleeding. The bleeding occurs even when recognizable pelvic pathology, pregnancy, or general medical disease is absent. It reflects normal cyclic disruption of endometrial lining ovulatory hormonal stimulation (Whitaker & Critchley, 2016).

Thoughts on the Treatment Plan of This Patient

Hormones treatment with progestin pill as this is not known to cause weight gain. The daily pill will regulate the patient’s menstrual cycle. FeSo4 daily pill as the patient is anemic (Bradley & Gueye, 2016).

Additional Information I Would Obtain to Assist in Determining Treatment Options

  • Whether the patient has a history of STI
  • Whether the patient has had an HPV infection
  • When was the last menstrual period
  • Whether there are any vaginal discharges and spotting between monthly periods

Guidelines I Would Consult

  • The American College of Obstetricians and Gynecologists (ACOG) guidelines
  • The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines

References

Bradley, L. D., & Gueye, N. A. (2016). The medical management of abnormal uterine bleeding in reproductive-aged women. American Journal of Obstetrics and Gynecology214(1), 31-44.

Whitaker, L., & Critchley, H. O. (2016). Abnormal uterine bleeding. Best Practice & Research Clinical Obstetrics & Gynaecology34, 54-65.

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Question 


Abnormal Uterine Bleeding

Discussion Topic 7 (Abnormal Uterine Bleeding)

***The initial discussion response should be in the range of 250-300 words. All questions in the topic must be addressed. All discussions need to be supported by a minimum of two scholarly resource. Journals and websites must be cited appropriately (Citation and reference must adhere to APA format). All components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with citations and references in APA format.

Jessica, a 38-year-old white female, has had three term births and one first-trimester spontaneous abortion (G4P3013). Her third child was delivered via cesarean section and she underwent tubal sterilization at that time.

She presents complaining of a 6-month history of fatigue. She reports no other symptoms, no recent illness or change to her physical or emotional health, including no depression or significant stress that might account for her fatigue. She does not smoke and uses alcohol only in social situations.

Abnormal Uterine Bleeding

Abnormal Uterine Bleeding

You order a complete blood count (CBC) with platelets, which reveals a hemoglobin level of 10.1 g/dL and hematocrit of 29.8; other RBC indices are consistent with iron deficiency. WBCs and platelets are within normal ranges. You also check her thyroid-stimulating hormone level, which, at 1.8 mIU/L, is within normal limits.

You inquired about her menstrual periods, she reports that they are regular, with bleeding lasting 7 to 9 days. She typically uses super-absorbent tampons, changing them approximately every two hours in the first couple of days of her period. She also relies on pads for backup during her days of heavier flow. She has noticed that she sometimes passes quarter-sized clots. While discussing these details, it becomes clear that Jessica has had heavy periods throughout her reproductive life, but she had never sought medical help because she had accepted her periods as a normal aspect of her life.

Jessica’s medical history is remarkable for hypertension and she currently takes 25 mg a day of hydrochlorothiazide. Her only other medication is a daily multivitamin. Her surgical history includes a tubal ligation. She reports no allergies.

She reports no intermenstrual or postcoital bleeding and is sexually active with only her husband. There is no family history of breast, ovarian, colon, or uterine/endometrial cancers and no history of abnormal Pap tests or positive screens for sexually transmitted infections.

On physical examination, Jessica is a well-developed, obese white female in no apparent distress. Blood pressure is 138/87, pulse 78, temperature 98.9°F, height 5’6”; weight 267 pounds, BMI 43.09 kg/m2. Aside from the obesity, there are no other relevant nonpelvic physical findings.

Abnormal Uterine Bleeding

Abnormal Uterine Bleeding

Her pelvic exam reveals no vulvar or vaginal lesions; a small amount of dark blood is present in the vault. There is no cervical motion tenderness or cervical lesions. Her uterus and adnexal structures are difficult to palpate because of her abdominal girth, though the uterus does not appear to be enlarged and there are no pelvic masses palpated.

Questions:

  1. With the above information, construct the subjective and objective data in a SOAP Note format.
  2. What is your assessment of this patient?
  3. What are your thoughts for treatment plan of this patient?
  4. Is there any other information that you would obtain to assist you in determining treatment options?
  5. Which guidelines would you consult?

Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with citations and references in APA format.

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