OBGYN MEDICAL HISTORY #1 Date: 11/17/21 Time: 14:50
IDENTIFICATION: L.L
Sex: F Race: Hispanic Nationality: US Age: 24 Marital status: Single
Address: n/a Religion: n/a
PCD: O. Dairo
Informant Self Reliability: Reliable Referral: None
CC: No period x 3 months
24 y/o F w no known PMH LMP 07/05 presents today with a complaint of absent periods for the past 3 months. Patient states this has never happened to her before and usually her periods are regular, every 28 to 30 days, last 5-6 days and present with a moderate amount of bleeding (reports using 2-5 pads/day, and seeing small clots). Patient also reports to having lower abdominal cramps few days out of a month, feeling like her “period is coming”, describing them as mild discomfort with 3/10 pain that does not radiate anywhere, denies any alleviating or aggravating factors. Denies being sexually active within the past 6 months or any known history of STI. States she has had multiple urine HCG tests, last being yesterday at Woodhull ED, all negative. Patient states that her cousin was diagnosed with PCOS at the age of 19. Denies any personal or family history of thyroid disease or cancer. Denies using any pharmacologic contraception or steroid use. Denies noting any discharge from breast. At the time of evaluation denies any abdominal pain, fever, chills, nausea/vomiting/diarrhea/constipation, denies urinary symptoms.
PMH: Denies
PSH: Denies
FH: Cousin – PCOS
Meds: Denies
Allergies: NKDA
Social: L.L. lives at home with her parents, currently in college. States she eats well balanced meals cooled by her family. Denies using any EtOH, smoking or using any nicotine products or use of illicit drugs. She states her sleeping patterns and appetite remain unchanged.
OBGYN: Denies ever being pregnant. LMP 07/05 as per HPI. Last PAP unknown.
Review of Systems:
General: Denies any fever, chills, night sweats, fatigue, weakness, loss of appetite
Skin, hair, nails: Denies any changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution
Head: Denies any headache, denies vertigo, unconsciousness, coma
Eyes: Denies photophobia, Denies visual disturbances, fatigue, lacrimation
Ears: Denies deafness, pain, discharge, tinnitus
Nose/Sinuses: Denies discharge, epistaxis, obstruction
Mouth and throat: Denies bleeding gums, sore tongue, difficulty swallowing
Neck: Denies localized swelling/lumps, stiffness/decreased range of motion
Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND
Cardiovascular system: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur
Gastrointestinal system: Denies changes in appetite, intolerance to foods, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank
Genitourinary: Denies frequency, incontinence, dysuria, nocturia, urgency, oliguria, polyuria, hesitancy, dribbling
Musculoskeletal system: Denies Muscle/joint pain, admits to swelling and redness of right hand and fingers
Peripheral Vascular system: denies intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change
Hematologic System: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE
Endocrine system: Denies generalized weakness, polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism
Nervous system: Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)
Psychiatric: Denies depression/sadness (Feelings of helpless, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder
Physical Exam:
General: Well developed non ill-appearing female in no apparent distress
Vitals:
H: 5.4 W: 145 BMI: 24.9
- BP: 118/78, RA, supine
- T: 36.8 C oral
- HR: 75 BPM
- O2SAT: 98% RA
- RR: 17, unlabored
Thyroid – Non-tender; no palpable masses; no thyromegaly.
Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored; no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.
Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.
Heart: Regular S1 and S1 with no murmurs or gallops. No splitting of S2 or friction rubs appreciated.
Abdomen: flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation
Breast: Tanner Stage 5. Non-tender to palpation throughout, no masses appreciated
Pelvic: Tanner stage 5. External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix closed, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted.
DDX:
Pregnancy
Hypothalamic amenorrhea (Stress, weight change, exercise)
Hyperprolactinemia
Hypothyroidism/Hyperthyroidism
Cushing Syndrome
If Excess Testosterone:
Low/Normal FSH:
Adrenal hyperplasia/Androgen secreting tumor
PCOS
Ovarian tumor
High FSH:
Autoimmune Ovarian Failure
Gonadal Dysgenesis (Ex: Turner syndrome)
Assessment:
24 y/o F is here with a c/o of amenorrhea. R/o pregnancy vs thyroid causes vs PCOS or hyperprolactinemia.
Plan:
Labs:
- Qualitative HCG
- FSH, LH, Testosterone, sex hormone binding globulin
~ free androgen index (defined as total testosterone divided by sex hormone binding globulin [SHBG] × 100, to give a calculated free testosterone level) – normal range is less than 5
- TSH, Free T4
- Serum Prolactin and Cortisol
- Hg A1C
- PAP smear
Endocrinology referral if negative workup
Patient reassurance and education
