Case Study: Dysfunctional Uterine Bleeding essay

Case Study: Dysfunctional Uterine Bleeding

• Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
• Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

• Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. It is to be set up like a soap note. ( will attach)

Case Study: Dysfunctional Uterine Bleeding

Gretchen Abernathy is a 38-year-old G2 P2 Caucasian female who presents to the clinic with complaints of frequent menstrual bleeding. Her menstrual calendar shows bleeding frequency 17-36 days, lasting 5-10 days in duration and on her heaviest day she needs to change her super tampon every 2 hours. She relates this has been getting worse since stopping her OCP’s when she had a bilateral tubal ligation 4 months after having her second child 9 months ago. She is upset as no one told her that weight gain could happen after and relates she has gained 27 lbs. since her surgery. She states that all this bleeding is making her tired and she cannot keep herself awake. Gretchen’s mother told her she probably just had “low iron” and if she took vitamins, she would feel better.
• HEENT: wnl, hair dry, neck supple without adenopathy
• CV: RSR without murmur or gallop
• Lungs: clear to p&a.
• Abd soft, non-tender, BS all 4 quadrant.
• VVBSU: WNL
• Cervix: firm, smooth, parous, w/o CMT
• Uterus: mid mobile non tender, approximately 10 cm
• Adnexa: without masses or tenderness
• Extremities: negative homan’s, reflexes 2+ = bilaterally, no edema