NU576 Unit 5 Journal

Student Name

Purdue University Globle 

NU576 NP II – Primary Care of Women’s Health

Prof. Name

Date

NU576 Unit 5 Journal

Irregular menstrual cycles in a 37-year-old woman following the discontinuation of birth control are commonly associated with hormonal imbalances, and Polycystic Ovary Syndrome (PCOS) is among the most likely causes. Comprehensive evaluation, including laboratory testing, pelvic ultrasound, and gynecological assessment, is essential to identify the underlying cause and develop an individualized treatment plan. Early diagnosis can also help reduce long-term risks such as infertility, type 2 diabetes, and cardiovascular disease.

Patient Information

• Patient Name: Cindy Haas

• Encounter Number: 1524523

• Date of Encounter: September 26, 2023

• Age: 37 years

• Sex: Female

Chief Complaint

The patient states, “My periods are wacky, and I would like to figure out why.”

History of Present Illness

Cindy Haas is a 37-year-old female who presents with abnormal menstrual patterns that have persisted for more than one year. She reports that her menstrual periods became noticeably shorter after discontinuing hormonal birth control, typically lasting only two to three days and requiring one to two sanitary pads per day.

She experiences lower abdominal cramping during menstruation but denies persistent abdominal pain or gastrointestinal symptoms. The patient has attempted symptom management using prenatal vitamins and acupuncture; however, these interventions have not significantly improved her condition.

Because of the prolonged changes in her menstrual cycle and concerns regarding reproductive health, the patient seeks further evaluation to determine the cause of her symptoms.

Current Medications and Allergies

Medications

• Over-the-counter prenatal vitamins

Allergies

• Sulfa drugs (causes rash)

Medication Intolerances

• None reported

Past Medical History

The patient denies any history of:

• Chronic medical conditions

• Major trauma

• Hospitalizations

• Surgical procedures

Family History

The patient’s family history is notable for several metabolic disorders:

• Mother: Diabetes mellitus

• Father: Hypertension

• Sister: Type 2 diabetes mellitus

This family history increases the patient’s risk for metabolic complications commonly associated with PCOS.

Social History

The patient has been married for 10 years and has worked as a teacher at Washington High School for approximately 15 years.

She reports:

• No tobacco use

• Social alcohol consumption, primarily wine on weekends

• No recreational drug use

Review of Systems

General

The patient denies recent weight changes but reports persistent fatigue and thinning hair, both of which may indicate an underlying hormonal imbalance.

Cardiovascular

The patient denies chest pain and palpitations.

Respiratory

She denies cough, congestion, and shortness of breath.

Skin

The patient denies bruising, rashes, and discoloration but reports dry skin.

Eyes

She denies blurred vision or vision changes and does not wear corrective lenses.

Gastrointestinal

The patient denies nausea, vomiting, constipation, and diarrhea. She reports lower abdominal cramping only during menstruation.

Genitourinary and Gynecological

The patient denies urinary symptoms such as dysuria or urinary frequency. She remains sexually active with her husband and reports abnormal menstrual bleeding.

Ear, Nose, Mouth, and Throat

The patient denies sinus issues, sore throat, and difficulty swallowing.

Musculoskeletal

She denies back pain, muscle aches, or joint stiffness.

Breast Health

The patient reports no breast changes and does not routinely perform breast self-examinations.

Neurological

She denies dizziness, weakness, and seizure activity.

Hematologic, Lymphatic, and Endocrine

The patient denies excessive thirst, excessive hunger, and a history of blood transfusions. She reports a previous HIV screening completed during a blood donation.

Psychiatric

The patient denies depression, anxiety, and prior psychiatric treatment or hospitalization.

Physical Examination Findings

Vital Signs

• Weight: 170 lbs

• Height: 5 ft 5 in

• Temperature: 37.1°C

• Blood Pressure: 120/70 mmHg

• Pulse: 68 beats/minute

• Respiratory Rate: 20 breaths/minute

General Appearance

The patient appears healthy, alert, and cooperative. She answers questions appropriately and demonstrates no acute distress.

Skin Examination

Skin is dry but intact, with no evidence of lesions or bruising.

HEENT Examination

• Head: Normocephalic and non-tender

• Eyes: PERRLA

• Ears: Symmetrical and patent bilaterally

• Nose: Nares patent

• Mouth: Dentition intact without evidence of dental caries

Cardiovascular Examination

Cardiovascular assessment reveals a regular heart rate and rhythm with normal S1 and S2 sounds. No murmurs, extra heart sounds, or peripheral edema are present.

Respiratory Examination

Breath sounds are clear bilaterally, and respirations are even and unlabored.

Gastrointestinal Examination

The abdomen is soft and non-tender with bowel sounds present in all four quadrants. Lower abdominal cramping occurs only during menstrual periods.

Breast Examination

Breasts are non-tender without masses, nipple discharge, or skin abnormalities.

Genitourinary Examination

The pelvic examination revealed:

• Normal vulva without lesions

• Normal vaginal mucosa

• Normal cervix without discharge

• Anteverted, non-tender uterus

• Non-distended, non-tender bladder

• Normal rectal tone

A Pap smear was obtained during the examination.

Musculoskeletal Examination

The patient demonstrates full range of motion in all extremities without pain or limitations.

Neurological Examination

Neurological findings include:

• Clear speech

• Steady gait

• Appropriate posture

• No focal deficits

Psychiatric Examination

The patient is alert and oriented to person, place, and time. Speech, behavior, and appearance are appropriate.

Diagnostic Testing and Laboratory Evaluation

Several diagnostic tests are recommended to determine the cause of abnormal uterine bleeding and evaluate for endocrine or metabolic disorders.

Recommended Laboratory Studies

• Complete Blood Count (CBC)

• Comprehensive Metabolic Panel (CMP)

• Ferritin level

• Pregnancy test

• Thyroid-Stimulating Hormone (TSH)

• Prolactin level

• Total testosterone level

These tests can help identify anemia, thyroid dysfunction, pregnancy-related causes, and androgen excess commonly associated with PCOS.

Imaging Recommendations

A pelvic ultrasound is recommended to assess:

• Polycystic ovarian morphology

• Uterine abnormalities

• Structural causes of abnormal bleeding, including fibroids

Assessment and Differential Diagnosis

Primary Diagnosis: Polycystic Ovary Syndrome (PCOS)

PCOS remains the leading diagnosis based on the patient’s menstrual irregularities, fatigue, thinning hair, and family history of metabolic disease. PCOS is one of the most common endocrine disorders among women of reproductive age and is associated with elevated androgen levels and ovulatory dysfunction.

Common manifestations include:

• Irregular or absent menstrual cycles

• Abnormal uterine bleeding

• Infertility

• Weight gain

• Insulin resistance

• Increased risk of type 2 diabetes

Differential Diagnosis: Endometriosis

Endometriosis should be considered due to the patient’s menstrual cramping and abnormal bleeding. This condition occurs when endometrial-like tissue grows outside the uterus and can contribute to chronic pelvic pain and fertility challenges.

Potential symptoms include:

• Pelvic pain

• Dysmenorrhea

• Abnormal bleeding

• Infertility

Differential Diagnosis: Uterine Fibroids

Uterine fibroids are benign uterine growths that may contribute to abnormal bleeding and pelvic pressure. Although the patient’s physical examination is unremarkable, imaging studies are necessary to exclude this possibility.

Treatment and Management Plan

Medication Management

Treatment recommendations should be individualized based on diagnostic findings and patient preferences.

Potential interventions include:

• Hormonal contraceptives for menstrual regulation

• Androgen-blocking medications for symptoms related to excess testosterone

• Symptom-based treatment following laboratory evaluation

Lifestyle Recommendations

Lifestyle modifications play a critical role in improving hormonal health and reducing long-term complications associated with PCOS.

Recommended strategies include:

• Maintaining a balanced diet

• Increasing physical activity

• Supporting healthy weight management

• Monitoring blood glucose levels regularly

• Attending routine preventive healthcare appointments

Patient Education

Patient education should focus on helping the individual understand the chronic nature of PCOS and its potential complications.

Important topics include:

• Type 2 diabetes risk

• Cardiovascular disease prevention

• Fertility implications

• Hormonal changes associated with PCOS

• Importance of follow-up evaluations

Educating patients about symptom monitoring and lifestyle interventions can improve long-term outcomes and quality of life.

Cultural Considerations

Healthcare providers should incorporate shared decision-making into treatment planning. Cultural beliefs, personal values, and preferences regarding hormonal therapy should be respected throughout the care process to improve treatment adherence and patient satisfaction.

Preventive Care Recommendations

Preventive health measures include:

• Routine cervical cancer screening according to current guidelines

• Age-appropriate breast cancer screening

• Regular wellness examinations

• Monitoring for metabolic conditions, including diabetes and hypertension

Referral and Follow-Up

Referral

Referral to an obstetrician-gynecologist (OB/GYN) is recommended for further evaluation, interpretation of diagnostic findings, and long-term management.

Follow-Up

A follow-up appointment should be scheduled in approximately 12 weeks to:

• Review laboratory and imaging results

• Assess symptom progression

• Evaluate treatment effectiveness

• Modify the care plan as necessary

References

Cleveland Clinic. (2023). Polycystic ovary syndrome (PCOS). https://my.clevelandclinic.org/health/diseases/8316-polycystic-ovary-syndrome-pcos

James, A. H. (2016). Heavy menstrual bleeding: Work-up and management. Hematology: American Society of Hematology Education Program, 2016(1), 236–242. https://doi.org/10.1182/asheducation-2016.1.236

NU576 Unit 5 Journal

Johns Hopkins Medicine. (n.d.). Uterine fibroids. https://www.hopkinsmedicine.org/health/conditions-and-diseases/uterine-fibroids

Mayo Clinic. (2018, July 24). Endometriosis: Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656