OBGYN HPI

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

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.