Year Young Woman Explained for Students (Easy Guide)

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Original Question

A 17-year-old young woman presents to her FNP with a 1-year history of irregular menses, including skipped menses, menorrhagia, and dysmenorrhea. She presents to the appointment with her mother. She started menarche at age 14 and states she has never really had regular menses. Over the past year, menses have increased in irregularity and flow with clots, with menstrual cramping. Menses are 7 days in length with mild to moderate clots. Patient uses tampons and changes them during menses, hourly for the first 3 to 4 days and then every 3 hours for the last 2 to 3 days of her menses. The patient states that about twice a year she does not have a menses and related that this is usually during a time of excess physical activity and stress. Review of Systems The patient’s ROS is positive for nausea, abdominal pain (menstrual cramping), heavy menstrual flow, and intermittent dizziness. Her ROS is negative for decrease in appetite, weight change, hair loss, vaginal discharge, depression, or fatigue. Relevant History The patient has no history of depression or eating disorders and no history of chronic medical problems or surgery. She lives with parents and siblings in a single-family home. She takes advanced placement classes in school in the 12th grade at the local high school. The patient is active in school and community sports, including dance, volleyball, and soccer. She has been very involved with sports in middle and high school. Her family history is positive for thyroid disorders and hypertension but negative for bleeding disorders. She denies being sexually active. She denies any eating disorder tendencies. She denies any usage of tobacco, alcohol, and drugs. Allergies No known drug allergies; no known food allergies. Medications None. Physical Examination Vitals: T 37°C (98.7°F); P 98; R 22; BP 108/62; WT 55.34 kg (122 lbs), 50th percentile; HT 165 cm (65 in.), 60th percentile; BMI 20. General: Appears mildly fatigued. Psychiatric: Affect is normal and appropriate. Head: Head is normocephalic. Hair distribution is normal without hair loss. Eyes: PERRL, red reflex present bilaterally. EOM full, positive nystagmus. ENT/Mouth: Tympanic membranes pearly gray with visible cone of light and landmarks. Mucosa is pink and moist. Normal speech and tone. Uvula midline. Neck: Neck supple, no thyromegaly, or adenopathy. Lungs: Respirations even and un-labored, clear bilaterally. Heart: Normal S1 S2 without rubs, murmurs, or gallops. Abdomen: Soft, non-tender, BS ×4, no organomegaly or splenomegaly. No costovertebral angle tenderness. Musculoskeletal: Moves all extremities well, equal strength, gait normal, DTRs 2+ bilaterally. Neurological: A&O×3, cranial nerves II to XII grossly intact. Sensory grossly intact to light touch symmetrically. Questions What is your assessment? List all differential diagnoses with positives and negatives and most likely final diagnosis List your final diagnoses with ICD Codes with rationale (may be more than one) List any test/labs etc. that you are considering ordering be specific with your rationale Develop a comprehensive plan of care following the guide below Lab/tests identify which labs/test from your list above you are going to order at this visit Pharmacological Medications with calculated dosages and prescription (if needed) & nonpharmacological treatments Patient Education (make sure this is written to the caregiver/patient in easy to understand working and using bullet points) Referrals (if needed) Follow up (next primary care visit, any other needed visits & reasons to go for emergency care) List appropriate references used to diagnose and treat the patient

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