Question

Dysmenorrhea

18 year old female for new patient visit c/o chronic pelvic pain.

Periods started at age 13 and were irregular, regular since age 15. They have been increasingly painful. For the past several months she has crampy pelvic pain throughout the month and pain that is so severe with her periods that she misses school or work. She went to the ED over the summer and was told she had a "huge cyst that was causing all of the issues", but when she followed up with her GYN he told her "it wasn't that bad and it wasn't causing her pain". She takes ibuprofen around the clock with her period but also takes it frequently throughout the month. She is frustrated and has switched offices to see if she can get answers.

PMH: None

Meds: None

Allergies: None

Pertinent Family hx: Mom and sister with endometriosis

Surgical Hx: None

Social Hx: Just started online college classes, working PT evening job. Lives with parents and sister. Sexually active x 1 partner. Condoms for birth control. No drug, ETOH, tobacco use.

Previous chart note reviewed: Provider mentions "dysmenorrhea, try NSAIDs".

Previous US from August: 3.9 cm hemorrhagic cyst on left ovary, otherwise normal TVS.

In SOAP format:

1.     Subjective: Write out the subjective information you have. Write what other information you would want to ask.

2.     Objective: Write out an objective assessment that you would expect to find. Include only the relevant systems.

3.     Assessment: What are your differential diagnoses? Include at least three. Write a rationale for each one.

4.     Plan: Based on the information provided, what would your plan be at this visit? Be sure to include relevant diagnostics, treatments, education, referrals, and follow up.

1. What is the relevance of the family history in this case?
2. The patient mentions that she was hoping for surgery to know if she has endometriosis. How would you respond to this inquiry?
3. At what size would you begin to counsel the patient about the risk for torsion? How would you educate them regarding this?

Answer 1

1) SUBJECTIVE : -
Dysmenorrhea is the medical term for painful menstrual periods which are caused by uterine contraction.

There are 2 types of DYSMENORRHEA:

-PRIMARY DYSMENORRHEA:

Primary dysmenorrhea is the name for common men trial cramps that come back over and over again which is also called as recurrent and aren't due to other diseases.

Pain usually begins one or two days before getting periods or when bleeding actually starts.

May feel pain from mild to severe in the lower abdomen, back or thighs.

-SECONDARY DYSMENORRHEA:

Menstrual pain from secondary dysmenorrhea is a result of problems with the reproductive organs.

Conditions that can cause cramping include: Endometriosis,Adenomyosis , Pelvic inflammatory disease (PID) and Fibroids (benign tumors)

INFORMATION WHICH WOULD LIKE TO ASK TO THE PATIENT ARE:

- When is the pain starts? Is it before bleeding or during bleeding?

- What are the other symptoms do you present along with pain?

- Ibuprofen is the drug of choice for you, is it give complete pain relieve or how frequently do you use pain killers?

- For how long the bleeding last? Whether the pain last after bleeding?

> In this case the subjective assessment of the patient is cramping pain throughout the month of mentrual cycle.

2)OBJECTIVE : -

objective assessment which is expected to find out are: -

- Pain concentrated in the lower abdomen or pelvis and may radiate to the thighs and lower back.

- Nausea and vomiting

- Diarrhea

- Headache

- dizziness

- Disorientation

- Fainting and fatigue.

3)ASSESSMENT : -

Differential diagnosis are Ectopic pregnancy, Pelvic inflammatory disease, Interstitial cystitis , Chronic pelvic pain, Elective abortion , Endometriosis, Ovarian cysts.

- ECTOPIC PREGNANCY: also called extrauterine pregnancy is when a fertilized egg grows outside a women uterus somewhere else in the belly.It also causes bleeding with severe pain.

-PELVIC INFLAMMATORY DISEASE: is an infection and inflammatory disorder of upper female genital tract including uterus, Fallopian tubes which also causes pain and bleeding.

- OVARIAN CYSTS: is a sac filled with liquid or semiliquid material that arises in an ovary which also cause bleeding and pain.

4) PLAN : -

RELEVANT DIAGNOSTIC :

Laboratory studies includes

Complete blood count to search for evidence of infection or neoplasticism process.

Gonococcal and chlamydial cultures to exclude sexually transmitted infections and pelvic inflammatory disease

Quantitative human chorionic gonadotropin level to exclude ectopic pregnancy

Erythrocytes sedimentation rate for subacute salpingitis

Urinalysis to exclude urinary tract infection

Stool guaiac to rule out GI bleeding

ULTRASONOGRAPHY- to evaluate situations such as ectopic pregnancy, ovarian cysts , fibroids and intrauterine contraceptive device.

HYSTEROSALPINGOGRAPHY - to exclude endometrial polyps , leimyomas and congenital abnormalities of the uterus .

INTRAVENOUS PYELOGRAPHY - is indicated if uterine malformation is confirmed as a cause or contributing factor for dysmenorrhea

TREATMENT-

Treatment for primary dysmenorrhea is providing relief for the cramps pelvic pain and associated symptoms which include NSAIDS such as diclofenac, Ibuprofen,Ketoprofen, meclofenamate , Mefenamic acid and naproxen.

Treatment of secondary dysmenorrhea involves correction of underlying organic cause which may be required to treat pelvic pathologic condition and to ameliorate the associated dysmenorrhea

DIET AND OTHER THERAPIES -

A low fat vegetarian diet is recommended which also includes pyridoxine, magnesium and vitamin E

Therapies includes acupuncture, acupressure, aromatherapy is recommended

For some patients continuous low level heat may be beneficial.

PREVENTION AND EDUCATION -

prevention and education includes lifestyle modification

educating for get out of smoking habits which can be a risk factor for dysmenorrhea

Exercise has been shown to alleviate symptoms of dysmenorrhea

RELEVENCES OF THE FAMILY HSITORY IN THIS CASE IS - Patient mother and sister has endometriosis.

Whether to do surgery to know that patient has endometriosis-

educate the patient about dysmenorrhea and endometriosis.symptoms and explain the patient that no need to do surgery to know whether the patient has endometriosis. Just need to do some of the investigations to find out.

Ovarian torsion is a condition that occurs when an ovary twists around the ligaments that holds it in place. This twisting can cut off blood supply to the ovary and Fallopian tube

Educate the patient about ovarian torsion and the signs and symptoms of the condition and the patient should follow up the doctor regularly for health check and for the regular diagnostic procedures.