Rotation 6

Identification:

Patient’s name: RM

Age: 25

Gender: Female

Race: Hispanic

Location: Woodhull Hospital, OBGYN clinic

Date: 7/17/19

Informant: self, reliable

CC: “Irregular menses since menarche”

HPI:

25 y/o F G0P0, LMP 2/1/19, with PMHx of constipation presents to the Women’s health clinic with irregular menstruation since menarche. States that she has approximately 3-4 x menstruations in one year, each time last about 3-4 days, medium flow without clots. She has not had a period for more than 5 months. Pt is currently sexually active with one partner, male only, and using condom inconsistently. Further states that she has gained 40-50 lbs in the past 5 months and has difficulty losing weight. Denies hx of STDs, abnormal vaginal discharge, abnormal Pap results, dyspareunia, pelvic pain, urinary symptoms, cold/hot intolerance/palpitation, hirsutism, galactorrhea, N/V, adult acne, facial hairs, significant headache or vision changes.

Differential Diagnosis:

Pregnancy- the first thing I want to rule out for amenorrhea for a woman in childbearing age. Pt is sexually active and using condoms inconsistently

Hypothyroidism- irregular menses and weight gain, hx of constipation.

PMH:

Constipation

Past Surgical History:

None

Medications:

None

Allergies:

NKDA

Family History:

Denies family hx of irregular menstruation, breast cancer, ovarian cancer, and colon cancer.

Social History:

Denies use of EtOH/cigarettes/illicit drugs. Denies exercising and healthy diet.

ROS:

General: Patient denies loss of appetite, generalized weakness, fatigue, fever, chill or night sweats. Admits to recent weight gain of 40-50 lbs in the past 5 months

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, rectal bleeding, blood in stool or stool guaiac test or colonoscopy. Admits to constipation.

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain

Menstrual and Obstetrical: Patient last normal period is 2/1/19, does not remember time of menarche, her menstrual cycle is irregular with medium flow without clots. Patient denies postcoital bleeding, dyspareunia, G0P0000. Last pap smear was 2 years ago, negative for malignancy.

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

Physical Examination:

General: 25 y.o obese female is alert and cooperative. She is well dressed and doesn’t appear to be distressed. Appears like her stated age.

Vital Signs:

BP (seated): 137/80

HR: 72 BMP, regular

RR:  14, not labored

Temp: 97.5 F oral

O2 sat: 100% room air

Height:5ft 1 weight: 257lbs  BMI: 48.6 obese

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution, no facial hair or chest hair

Nails: not performed

Head: not performed

Eyes: not performed

Ears: not performed

Nose: not performed

Sinuses: not performed

Lips: Pink, dry, no cyanosis or lesions

Mucosa: not performed

Palate: not performed

Teeth: not performed

Gingivae: not performed

Tongue: not performed

Oropharynx: not performed

Neck: No masses, lesions or scars. Trachea midline. Supple nontender to palpation.

Thyroid: Nontender, no palpable masses, no thyromegaly.

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR.

Breast: Normal contours, no nodules, mass, tenderness, nipple discharge or dimpling.

Abdomen: Flat, symmetrical, no scars, Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness.

Female genitalia: External – normal pubic hair pattern, no erythema, inflammation, ulcerations, lesions or discharge. Vaginal mucosa without inflammation, erythema or discharge. Cervix without lesions or discharge. No cervical motion tenderness. Uterus mobile, non-tender and of normal size, shape, and consistency. Adnexa without masses or tenderness

Rectal: not performed

Peripheral vascular: not performed

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve: not performed

Motor/Cerebellar: not performed

Sensory: not performed

Reflexes: not performed

Upper extremities and lower extremities musculoskeletal: Not performed

Imaging and lab works:

Transvaginal ultrasound: pending (patient needs to make an appointment for ultrasound)

Pelvic ultrasound: pending

DHEA sulfate: 152

LH: 11.1

FSH: 5.1

TSH: 1.2

Estrogen level: wnl

Lipid Panel: cholesterol 128, HDL 40, TG 90, LDL 70, cholesterol/HDL ratio 3.2

CMP: wnl

CBC: wnl

Hgb AlC: 6.3

Testesterone, free: 2.4

Testeterone, total: 39.7

Urine pregnancy test: negative

Prolactin: 17

Assessment:

25 y/o female presents with oligomenorrhea, weight gain, and elevated A1C, most likely secondary to PCOS.

Differential Diagnosis:

PCOS: oligomenorrhea, weight gain, and elevated A1C. Will need ultrasound to further assess.

Hypothyroidism- irregular menses and weight gain, hx of constipation. Less likely due to lab shows normal TSH.

Hyperprolactinemia or other hormonal abnormalities- irregular menses, weight gain. Less likely due to normal level of prolactin, normal FH, normal LH, normal testosterone.

Premature ovarian failure: irregular menses, but less likely due to normal levels of hormones

Anatomical problems – irregular menses, but will need ultrasound to further assess.

Plan:

Nutritionist referral

Life style modification – with 10% weight loss over the next 6 months

Advise patient to keep her ultrasound appointment

F/U in 1 month after ultrasound result come back

Patient Education:

Irregular menses can be due to many reasons. We will do lab work to find out what is going on with your menstruation. PCOS is one of the common cause for irregular menses and monthly ovulation is not occurring. It occurs in about 10% of women. Most women with PCOS are obese and insulin resistance. Although PCOS is not completely reversible, there are a number of treatment that can reduce or minimize bothersome symptoms.  Most women with PCOS are able to lead a normal like without significant complications. We will set you up to talk to a nutritionist for diet modification. You are also encouraged to exercise and set up a goal with 10% weight loss over the next 6 months. Make sure that you keep your ultrasound appointment so that we can better help you with your symptoms. You will need to come back in 1 month for a follow up appointment. We will see how you have changed. Oral contraceptives can be used for regulating your menses, but weight loss is one of the most effective approaches for managing insulin abnormalities, irregular menstrual periods, and other symptoms of PCOS.

HP1