Question
Answered step-by-step
Asked by LieutenantBravery8166
Kristin Cole is a 31 year old female who presents to your primary care office with complaint of heavy, irregular menses. She reports she has been having difficult menstrual periods for 3 or 4 years. Her fiancé urged her to come in for an appointment, especially because they have been wanting to have a baby. She has not used any contraception for 5 months. Since her menses is irregular, she sometimes does not get a menstrual cycle for 8 weeks, but then when she buys the kit to check for pregnancy, it is negative; then she gets a heavy cycle sometimes with small clots. She has never had a pelvic exam and knows very little about her family history, except that she herself was a large baby weighing over 9 pounds. Kristin works as a cashier and spends a lot of time on her feet. She feels tired and frustrated. On top of that, she is having to buy acne cream and shave annoying little hairs that grow on her chin. She just wants to be normal, get pregnant, and look and feel better.
Vital Signs: 141/88, 82, 16, 98.2 weight 240 height 64in
General: Obese, good hygiene
Head/Neck: Thyroid without tenderness or nodules. No cervical lymphadenopathy
ENT: gross hearing intact no rhinorrhea mucous membranes pink moist.
Neurological: Alert oriented x3 PERRLA. Normal gait and station.
Cardiovascular: PMI non displaced S1S2 no murmur gallop or rub
Respiratory: Regular easy even LS CTA no coughing
Abdominal: Soft BS x4 non-tender. No masses no hepatomegaly no splenomegaly.
Musculoskeletal: Muscle tone fair without atrophy and strength ¾ all extremities. No joint deformities. Good ROM shoulders hips back and feet.
Genitourinary: Labial folds without lesions or erythema, Non tender and no swelling skene and Bartholin glands, Cervix pink with transition zone small white discharge. Bimanual exam neg CMT, non-palpable ovaries, uterus fundus smooth normal size, no masses or tenderness.
Breast Exam: Breasts large bilaterally with some enlarged darkened areolar area. Skin without any rashs dimpling or erythema. Nipples without discharge. No masses or nodules palpated and no lymphadenopthy
Extremities: Pink warm dry 1+ pedal pulses no edema 3 second cap refill
Skin: Stage 2 pustular acne noted face and upper back. Skin has some increased pigmentation neck area and small coarse dark hair stubble on chin noted.
Questions:
What are some of your differential diagnoses in this case?
What other information would you seek from this patient?
What tests or diagnostic tools would you consider in this case, if any?
What is your final diagnosis?
What treatment and follow-up plan would you recommend in this case?
What patient education would you provide this patient?
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SCIENCE
HEALTH SCIENCE
NURSING
