Nu631U7peerresponsePaige

Subjective:

CC: Pt c/o 6-month history of fatigue

HPI: Pt is a 38yo white female who presents to the clinic with a complaint of fatigue x6 months. Pt denies other health concerns or changes, recent illness, depression, or stress. Pt with PMH of obesity and Hypertension. She is currently taking Hydrochlorothiazide 25mg PO and a multivitamin daily. Pt reproductive history of three term childbirths and one first trimester spontaneous abortion. Her third child was delivered via cesarean section where she also received a tubal ligation. Pt states that her menstrual cycle is regular, with menstruation lasting 7-9 days with a flow requiring super-absorbent tampons q2-3 hours and pads as back up for the first couple days of her period. Pt reports occasionally passing quarter-sized blood clots. Pt adds that this is how her periods have been since they started, and she has never sought medical treatment for the heavy, prolonged periods. Pt denies postcoital or intermenstrual bleeding. Pt is sexually active in a monogamous relationship with her husband and denies h/o abnormal pap smear to STI.

PMH:

Pregnancy Hx: G4T3P0A1L? – Mode of delivery unknown for first two births. Third birth done via cesarean section with bilateral tubal ligation. SAB in 1st trimester.  

Gynecological Hx: Patient denies history of STI or abnormal pap smear.

General Hx: Hypertension, Obesity, Menorrhagia

Surgical Hx: Cesarean section with bilateral tubal ligation

ALLERGIES: NKDA

MEDICATIONS:

Hydrochlorothiazide 25mg PO QD (Hypertension)

Multivitamin PO QD

SOCIAL HX:

Pt is married with 3 children, however living status of children is not known. Pt denies smoking and reports social alcohol consumption of undisclosed frequency or amount.

FAMILY HX:

No specific health history provided, but pt denies family h/o ovarian, colon, breast, or endometrial cancer.

Review of Systems:

GENERAL: Reports fatigue x6 months.

GYN: Reports regular cycles with menstruation lasting 7-9 days and use of super-absorbent tampons with back up peri pads for the first few days and occasional quarter-sized blood clots for the duration of her reproductive life. Denies postcoital or intermenstrual bleeding.

PSYCH: Denies depression, significant stress, or changes to her emotional health.  

Objective:

GENERAL: Well-developed, obese female exhibiting no signs of distress.

VS: Ht 5’6”, Wt 267lbs, BMI 43.09kg/m2, HR 78bpm, BP 138/87, Temp 98.9F

GI: Large abdominal girth

GYN: No vulvar or vaginal lesions, scant dark blood in vaginal vault, no cervical motion tenderness, no cervical lesions. Uterus and adnexal structures difficult to palpate d/t habitus, but no pelvic masses or enlarged uterus noted.

DIAGNOSTIC TESTS: CBC – HgB 10.1g/dL, HCT 29.8%, WBC and PLT WDL, RBC indicative of iron deficiency, TSH 1.8mIU/L

What is your assessment of this patient?

My assessment of this patient is that her fatigue could be attributed to iron deficiency anemia, menorrhagia, and obesity.

What are your thoughts on the treatment plan of this patient?

The patient would benefit starting iron supplementation. I would start her on Ferrous Sulfate 325mg PO BID and educate her about the consumption of iron rich foods, such as green leafy vegetables, legumes, organ meats, and iron enriched pasta. I would also discuss the need to correct/improve the patients menorrhagia and educate her on what a normal menstrual cycle should look like. I would discuss the options of an endometrial ablation, hysterectomy or contraceptives. Hysterectomy is the only definitive, curative treatment option (Tempfer & Keck, 2022). If she declined those three options, I would offer a non-hormonal medication, Tranexamic Acid 650mg 2 tablets PO TID x5 days during menstruation. The patient also needs to address her obesity, as this can contribute to fatigue. By making lifestyle changes that include a healthy, well-balanced diet and regular movement and exercise, she will see an improvement in her fatigue (Alexander et al., 2023).

Is there any other information that you would obtain to assist you in determining treatment options?

I know that the patient had a tubal ligation, but I have personally delivered a baby to a woman who had undergone this procedure, so I would inquire about the date of her LMP and get a UPT to be certain that pregnancy was not the cause of this fatigue. I would order a transvaginal US to assess for fibroids or masses, as this is recommended to be the first-line imaging for abnormal uterine bleeding (Alexander et al., 2023). Because I do not know the date and cannot see the results of her last pap smear, I would perform this during our visit. I would screen for UTI, STI, and vaginosis. I would also want to get more information on whether the patient snores or wakes throughout the night, and, if so, I would want a sleep study to rule out sleep apnea, which could be contributing to her fatigue, obesity, and hypertension.  

Which guidelines would you consult?

I would consult the care guidelines from American College of Obstetrics and Gynecology (ACOG) for abnormal uterine bleeding in non-pregnant, reproductive-aged women.

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