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Elizabeth Varona-Martin
The clinic experience continues to be very busy. It is easy to become disoriented in such a fast-paced environment. However, the skills I’ve learned and the understanding I’ve gained are priceless. Although I am far from an expert, I am acquiring more knowledge than I came with, and I am no longer intimidated by the idea of deciding on my own.
A 21-year-old patient comes to the office for her annual physical. When assessing the patient, she stated been concerned about her painful periods. Pain is intense, graded 9/10, described as cramps, disabling that begins on the second day of her menstruation. She has menarche at age 12. It also refers to headaches. Abdominal pain is recurrent, starts a few hours before the menstrual cycle, lasts 48 to 72 hours, radiates to the back, uses ibuprofen to relieve the pain, and is accompanied by heavy menstrual bleeding. She needs to change her pads every 2 hrs or less.
Other symptoms include asthenia, headache, abdominal distension, nausea, and diarrhea. The patient’s menstrual period usually lasts seven to ten days.
Current medication: Ibuprofen 800mg 1 tab PO as needed for pain
Physical examination of the external genitalia, vagina, and cervix was unremarkable.
Vital signs
Ht: 5’5 WT: 118.7 lb BMI: 19.8 B/P: 122/82 HR: 74bpm RR: 16 RPM O2Sat: 99%
Differential Diagnosis:
Pelvic inflammatory disease (PID) ICD10-CM N73.9: Typically, it manifests as a sudden onset of acute lower abdomen discomfort following menstruation. Common signs and symptoms include abdominal, pelvic, and lower back pain, atypical vaginal discharge, intermenstrual or postcoital bleeding, fever, nausea and vomiting, and urinary frequency (Schuiling & Likis, 2022).
Endometriosis ICD10-CM N80.9: is generally asymptomatic. Pelvic pain, including dysmenorrhea and dyspareunia, infertility, or an ovarian tumor, are common symptoms. Other symptoms include bowel and bladder problems, irregular uterine bleeding, low back discomfort, and persistent fatigue, but are less prevalent (Schuiling & Likis, 2022).
Adenomyosis ICD10-CM N80.0 Endometrial glands and stroma are present within the myometrium or uterine musculature, causing hypertrophy of the adjacent myometrium. Symptoms of adenomyosis include uterine hypertrophy, irregular uterine flow, and uncomfortable menstruation ( Stewart, 2021).
Impression and Plan
Primary Diagnosis:
Annual wellness exam ICD10-CM Z00.00
Dysmenorrhea ICD10-CM N94.6
Transvaginal ultrasonography was ordered to rule out underlying pathology, despite an unremarkable physical exam.
Treatment:
- Continue Ibuprofen 800 mg every 8 hrs orally as needed for pain
- Nortrel 0.5mg/35/28 1 tab orally daily as indicated
The patient was placed on Combined hormonal contraceptives because she was interested in both cycle management and contraception.
Patient education:
We advised the patient to use heat treatment to alleviate menstruation pain. Stress management, restricting soda and sugary meals have all been demonstrated to reduce reported pain levels.
Understanding dysmenorrhea is an important lesson that will help me develop as a healthcare professional. Persistent, crampy, lower abdomen pain during menstruation can occur at any moment during the patient’s reproductive years. Primary dysmenorrhea usually develops in adolescence, when ovulatory cycles have established themselves. Maturation of the hypothalamic-pituitary-gonadal axis, which leads to ovulation, happens at varying rates; roughly 18 to 45 percent of teenagers experience ovulatory cycles two years after menarche, 45 to 70 percent by two to four years, and 80 percent by four to five years. Because secondary dysmenorrhea is menstrual discomfort caused by another disease, the symptom often starts later in life and correlates with the underlying pathology’s progression, such as endometriosis, adenomyosis, or leiomyoma.
Dysmenorrhea may be so severe that it interferes with everyday activities, typically leading to absences or lower productivity concerning school, work, and other commitments, in addition to impairing the quality of life (Smith & Kaunitz, 2021).
Primary dysmenorrhea is defined as the presence of persistent, crampy, lower abdomen discomfort during menstruation in the absence of any condition that might explain these symptoms. Adolescents and young patients are more likely to be diagnosed with primary dysmenorrhea (Smith & Kaunitz, 2021).
Secondary dysmenorrhea happens in patients with a condition causing their symptoms, such as endometriosis, adenomyosis, or uterine fibroids. Patients suffering from these conditions frequently exhibit clinical symptoms that distinguish them from primary dysmenorrhea, such as an enlarged uterus, discomfort during intercourse, and resistance to therapeutic therapies (Smith & Kaunitz, 2021).
Any process or anomaly that might cause discomfort with menstruation is included in the differential diagnosis. Identifying aspects of dysmenorrhea include the recurring nature of the pain and its timing with menstruation, in addition to the pain itself. When all other possible causes of dysmenorrhea have been ruled out, the diagnosis of primary dysmenorrhea is made. If an underlying cause of dysmenorrhea is discovered, the diagnosis is changed to secondary dysmenorrhea (Smith & Kaunitz, 2021).
A complete history and physical examination are performed to search for signs and symptoms of pelvic pathologies such as pelvic inflammatory disease, endometriosis, adenomyosis, or fibroids. Laboratory testing, imaging examinations, and laparoscopy are conducted as needed (Smith & Kaunitz, 2021).
References
Schuiling, K. D., & Likis, F. E. (2022). Gynecologic Health Care: With an introduction to prenatal and postpartum care (4th ed.). Jones & Bartlett Learning.
Smith, R. P., & Kaunitz, A. M. (2021, July 29). Dysmenorrhea in adult females: Clinical features and diagnosis. UpToDate. Retrieved November 24, 2021, from https://www.uptodate.com/contents/dysmenorrhea-in-adult-females-clinical-features-and-diagnosis?search=dysmenorrhea&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2.
Stewart, E. A. (2021, October 29). Uterine adenomyosis. UpToDate. Retrieved November 24, 2021, from https://www.uptodate.com/contents/uterine-adenomyosis?search=Adenomyosis&source=search_result&selectedTitle=1~61&usage_type=default&display_rank=1.
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