Case Study- Menorrhagia/ Metorrhagia

1. Case Study- Menorrhagia/Metorrhagia Telana Fairchild, RN, NP Student UmassGSN 2/11/2014

2. Chief complaint | | Case Study- Menorrhagia/Metorrhagia “I’ve been having irregular periods since December.”

3. History of the present illness | | Case Study- Menorrhagia/Metorrhagia • 40yo female here because she is experience irregular, heavy menses • Two weeks late in December, lasted for 9 days (12/30-01/07) with heavy bleeding and clots (about six tampons daily & tampon and pad at night) • Period again on 1/21, first two days of period heavy but flow has decreased since last night • Typical cramping and soreness in pelvis for first 24hours, now has no pain • Feels more tired than usual since period in December • Denies irregular menses in past • Concerned about premenopausal because desires to have fertility treatment in order to have a child • Appointment with fertility specialist in Springfield on 02/20/2014. • Concerned her blood values are low, she has taken iron in the past • Denies feeling feverish, chills, lightheaded or dizzy today • Denies use of any medications, OTC, herbs, or therapies for her symptoms • LNMP: 11/15/2013

4. Medications and Allergies | | Case Study- Menorrhagia/Metorrhagia Citalopram 20mg PO daily for depression Labetalol 100mg PO BID for HTN Amitriptyline 50mg PO daily at bedtime for insomina Prenatal/folic acid 1 tab PO daily Trazodone50mg PO prn at bedtime for insomnia Rantidine150mg PO BID, prn for heartburn Denies other prescription meds, OTC, and herbals. Allergies: Zirthromax- rash Denies allergies to other medication, food, environmental, latex, or IV contrast

5. Past history: Medical and Surgical | | Case Study- Menorrhagia/Metorrhagia Acid Reflux 10yrs Depression 20 yrs HTN for 2 yrs Insomnia for 32yrs Malignant breast neoplasm age 21- Right breast partial mastectomy with lymph node removal 1994

6. Family History | | Case Study- Menorrhagia/Metorrhagia Father (1949): HTN, HL, MI before 50. Mother (1950): HTN Sister (1975): Healthy PGF/PGM: Unknown MGF (1928): HTN, HL, Smoker, skin cancer MGM (1931): HTN, HL, breast cancer Pt denies FH of stroke, DM, Thyroid Dx, Renal Dx, arthritis, TB, asthma, lung disease, HA, seizure disorder, suicide, lung CA, ovarian CA, colon CA, prostate CA and genetically transmitted disease (sudden death).

7. Social History | | Case Study- Menorrhagia/Metorrhagia ETOH- rare, maybe one beer once every month Smoking: Denise, never Illicit Drugs: Denies use marijuana, cocaine, crack, heroin, huffing, bath salts, Ecstasy, Hallucinogens, Amphetamines, PCP, and prescription drugs prescribed or otherwise. Caffeine: 1 (16oz) coffee every day

8. Review of Systems | | Case Study- Menorrhagia/Metorrhagia General:Complains of tiredness. Denies recent weight change, clothing that fits more tightly or loosely than before; weakness, fever, and chills. Psychiatric:Has depression and sleep disturbances both are controlled with medications. Denise nervousness, tension, mood changes, anxiety, memory change, and suicide ideation or attempts. Skin: Denies lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles. Respiratory: Denies cough, congestion, hemoptysis, dyspnea, wheezing, pleurisy, bronchitis, emphysema, pneumonia, and tuberculosis. No respiratory studies have been done at this time.

9. Review of Systems | | Case Study- Menorrhagia/Metorrhagia Cardiovascular: Denies “heart trouble,” rheumatic fever, heart murmurs, chest pain, chest discomfort, palpitations, HTN, HL, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and edema. No cardiac testing has been done. Gastrointestinal: Denies trouble swallowing, heartburn, appetite, nausea. Bowel movements once daily, brown, formed moderate size. Denies pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver or gallbladder trouble, and hepatitis. Urinary: Denise frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, hematuria, urinary infections, suprapubic pain, incontinence. 

10. Review of Systems | | Case Study- Menorrhagia/Metorrhagia Genital: 14yo at menarche, usually cycle is every 28-32 days for 5-6days, heaviest day is first and second day then light others. No contraception. Negative pregnancy test 12/2013. Denies bleeding after intercourse or between periods. Last intercourse was 01/18/2014. 1 male partner of two years. 3 sexual partners since sexually active at age 18yrs. G0. Denies sores, lumps, odor, sexually transmitted infections and treatments. Denies function problems and dyspareunia. Breasts: Denies lumps, pain, or discomfort, and nipple discharge. Denies self-examination practices. Hematological:History of anemia. Denies easy bruising and bleeding.

11. Physical Exam | | Case Study- Menorrhagia/Metorrhagia VS: T- 97.7 P- 100, repeat78 R- 28, repeat18 BP- 126/84 Ht- 71 Wt- 170 BMI- 23.7 General Survey: Pt alert, appears well nourished, developed, and groomed. No acute distress. Mental Status: Pt is alert and oriented x3, relaxed, cooperative. Thoughts flow logically and coherent with good memory and concentration. Skin:Pale with rosy cheeks, warm, dry, intact without lesions, rashes, and suspicious nevi.   HEENT: Mucous membranes are pink and moist

12. Physical Exam | | Case Study- Menorrhagia/Metorrhagia CV: S1S2, regular, without murmurs, bruits or extra sounds. Palpable pulse +2 bilaterally carotid, radial, DP and PT.  Lungs: Regular respiratory rate, full depth and unlabored rhythm, no use of accessory muscles. No audible adventitious sounds without stethoscope. Anterior-posterior thorax is stable and symmetric with equal and age-appropriate expansion.   Abdomen: Flat without abnormal movements, pulsations, veins, scars or rashes. BS active in all four quadrants. Tympany in all regions. No HSM (hepatosplenomegaly). Negative rosvigns, murphys, psoas, obturator and rebound tenderness signs. No inguinal lymphadenopathy.  

13. Assessment | | Case Study- Menorrhagia/Metorrhagia Menorrhagia Metorrhagia Female infertility

14. Plan of Care | | Case Study- Menorrhagia/Metorrhagia • Diagnostic:CBC and Iron studies • Therapeutic: Continue all medication as prescribed. Encouraged to eat iron rich food. Encouraged to drink plenty of water (60oz/day). • Education: Avoid NSAID and ASA as these make bleeding worse. Explained to keep journal as well as how many tampons/pads used to help quantify amount of bleeding. Explained there are many reasons for irregularities including stress, blood clots, menopause, and even cancer and that at this time not necessary for further test. Pt was educated about signs and symptoms of anemia and to seek treatment at ER if these developed.

15. Plan of Care | | Case Study- Menorrhagia/Metorrhagia Referral: Pt encouraged to keep appointment with specialist and review these details with them. F/U: However, if this period last longer than 7-10 days would need to return to office for further work up including GYN exam and PAP and possibly a transvaginal u/s. We will call with test results from today’s labs. F/u in one month, after menses.

16. Relevant laboratory or other diagnostic data WBC 4.8 3.8-10.8 RBC 3.19 3.80-5.10 Hgb 8.3 11.7-15.5 Hct 25.7 35-45 MCV 80.6 80-100 MCH 26.0 27-33 MCHC 32.2 32-36 RDW 13.3 11-15 Plt 380 140-400 Ferritin 4 10-232 Iron 16 40-175 IBC 426 240-450 % Sat 4 15-50 | | 16 Case Study- Menorrhagia/Metorrhagia 2/11/2014

17. Assessment | | Case Study- Menorrhagia/Metorrhagia Menorrhagia Metorrhagia Female infertility *Iron Deficiency Anemia

18. Plan of Care- revised | | Case Study- Menorrhagia/Metorrhagia • Diagnostic: none further at this time • Therapeutic:Start Ferrous Sulfate 325mg PO TID and Colace 100mg PO daily, Mirilax as directed prn constipation • Education: Explained lab results, iron deficiency anemia. Ferrous Sulfate is iron, will help restore bodies iron deficiency and increase RBC’s. Take ferrous sulfate with full glass of water. Try to take ferrous sulfate on an empty stomach, at least 1 hour before or 2 hours after a meal. However, if GI irritation can take with food will just decrease absorption. Avoid taking antacids or antibiotics within 2 hours before or after taking ferrous sulfate. Do not break, crush, and divide pill, take whole.

19. Plan of Care- revised | | Case Study- Menorrhagia/Metorrhagia Education:Ferrous sulfate can cause constipation, take colace stool softener daily while taking ferrous sulfate. Also can use Mirilax if constipation persist more than 2-3 days. F/U: Reminded about keeping appt with specialist. Return to office in one week for lab work and keep f/u appt. Reminded to call with new or worsening symptoms or report to nearest hospital.

20. Articles • Iron deficiency anemia during pregnancy and risk of LBW. • Should use iron supplement • Interesting protocol studied to better monitor anemia in pregnancy • Hgb most used but low accuracy • Ferritin most reliable but cutoff issue • Use of erythrocyte and ferritin as new protocol as gold standard

21. Thank You | | Case Study- Menorrhagia/Metorrhagia References: Bickley, L. (2012). Bates’ guided to physical examination and history-taking [Kindle version]. Retrieved from Amazon.com Dains, J.E., Baumann, L.C., & Scheibel, P. (2012). Advanced health assessment & clinical diagnosis in primary care. [Kindle version]. Retrieved from Amazone.com Dunphy, L.M, Winland-Brown, J.E., Porter, B.O., & Thomas, D.J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadephia, PA: F.A. Davis Company. Haider, B.A., Olofin, I., Wang, M., Spiegelman, D., Ezzati, M., & Fawzi, W.W. (2013). Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis. British Medical Journal, 346. doi: 10.1136/bmj.f3443 Woo, T.M., & Wynne, A.L. (2012). Pharmcotherapeutics for nurse practitioner prescribers (3rd ed.). Philadeplphia, PA: F.A. Davis Company.