NRNP-6552 WEEK 3 Gynecologic Health

·         A 31-year-old nulliparous woman visits the clinic for a routine gynecological exam.

·         She was recently married but denies any major complaint.

·         She reports that in the last three months, her menses have been irregular where there was a month of amenorrhea that was followed by two cycles in a month.

·         Her last menstrual period was two weeks ago and states that it was heavier than normal as she had to change a tampon every hourly in the first two days.

·         She states she is not using any contraceptive as she and her husband want to conceive.

·         She attained menarche at 10 years and has had a normal cycle length of five days until three months ago.

·         She denies history of sexually transmitted illness and pregnancy.

·         She is allergic to penicillin and is currently taking prenatal vitamins.

·         She lives with her husband and is a housewife after being forced to quit her job after marriage.

·         She drinks one or two glasses of wine a day but does not smoke.

Other subjective data I would need include:

a)      If the patient has been experiencing any dysmenorrhea during her period.

b)      If the patient has been experiencing increased stress levels due to her recent marriage and loss of employment.

c)      The patient’s recent mood, appetite, and mental health state to indicate any underlying mental health illness (Karrouri et al., 2021).

Objective findings.

·         Vitals: BP-109/66, Resp. rate 16, temperature 97.3F, weight 101lbs, height 64’’, BMI 17.3

·         General examination reveals a withdrawn patient who is orientated, fails to make eye contact.

·         She also appears disheveled and underweight.

·         Her skin is warm, dry, and intact, but there is a bruise in the inner thigh.

·         An abdominal examination reveals a soft and non-tender abdomen with four bowel sounds were heard on auscultation.

·         The pelvic examination revealed:

a)      Normal hair distribution with absent lesions and erythema on the external genitalia.

b)      Speculum examination findings were non-significant.

·         The breast examination was normal.

Additional objective data I would have needed is:

a)      If there is presence of pallor and petechial hemorrhages on mucosal sites.

b)      A detailed mental status examination.

c)      A neck examination to exclude any enlarged thyroid(Zamwar et al., 2023).

·         Complete blood count to evaluate platelet and red blood cell count due the associated period of menorrhagia (Jain et al., 2023).

·         Thyroid function tests to detect for presence of any hyperthyroidism or hypothyroidism as factors that contribute to menstrual irregularities and changes in the integument system.

·         Coagulation screen as defects in clotting factors are associated with menorrhagia.

·         Hamilton Depression Rating Scale (HDRS) to screen for depression in this patient.

·         A pelvic ultrasound to detect for any pelvic abnormalities that may cause menorrhagia.

1.      Major Depressive Disorder (MDD)

· MDD is a psychiatric condition characterized by mood changes which may have resulted from various triggers, including a recent marriage, loss of employment and probable domestic abuse evidenced by a bruise in her inner thigh.

· Some symptoms of MDD seen in Maxine include social withdrawal, self-neglect, and difficulty maintaining eye contact.Some patients may also overindulge in alcohol consumption as a coping mechanism (Karrouri et al., 2021).

· In addition, some patients with MDD may experience appetite loss and unintentional weight loss as seen in Maxine where she has lost more than 21 lbs in the last year.

· MDD can also be associated with increased stress levels associated with menstrual changes including amenorrhea (Jain et al., 2023).

2.      Hypothyroidism

· Hypothyroidism is a condition characterized by production of low levels of thyroid hormones T3 and T4.

· Thyroid hormones affect multiple body systems, including the central nervous, integument, gastrointestinal, and genitourinary systems (Zamwar et al., 2023).

· As a result, female patients with hypothyroidism often experience menstrual irregularities, such as menorrhagia.

· In addition, their skin appears dry and may have hair loss. The patients also have cold intolerance and have mood symptoms including depression.

3.      Thrombocytopenia

· Thrombocytopenia is a condition characterized by low platelet counts and may be caused by heavy alcohol consumption and poor nutrition.

· Thrombocytopenia is a common cause of abnormal uterine bleeding such as menorrhagia and polymenorrhea (Gerema et al., 2023).

MDD

·         I would prescribe antidepressants for the patient including a selective serotonin receptor inhibitor like sertraline 50 mg PO OD or Prozac 20 mg PO OD (Karrouri et al., 2021).

Hypothyroidism

·         I would prescribe Levothyroxine 75 mcg PO OD ((Zamwar et al., 2023).

Other treatment plans would include:

·         I would also involve a nutritionist to plan an appropriate diet for Maxine, thus correct her low BMI.

I would refer the patient for psychotherapy for couple or cognitive-behavioral therapy (CBT) (Karrouri et al., 2021).

Social Determinants of Heath (SDoH) for your chosen case.

· In Maxine’s case, loss of employment and possible partner abuse limits her financial independency which may make it difficult for her to access health care services.

·  MDD patients often experience social withdrawal resulting in isolation and lack of social support which may further worsen the prognosis (Remes et al., 2021).

· It is also crucial to understand Maxine’s social support system while at home who can protect and provide essential services that may empower her menstrual and mental health.

It is also crucial to provide easily accessible mental health services to Maxine to reduce the incidence of comorbid conditions, such asanorexia nervosa, anxiety, substance or alcohol use disorders, and suicide thoughts which may worsen the prognosis.

·         Gynecologist

A gynecologist review is crucial as they would help diagnose the specific cause of the abnormal uterine bleeding (Gerema et al., 2023).

·         Endocrinologist

A possible diagnosis of hypothyroidism makes it crucial for an endocrinologist review to evaluate whether it is the cause of the hypothyroidism and dry skin ((Zamwar et al., 2023).

·         Psychiatrist and Psychologist

I would recommend a psychiatrist who would help tailor the patient’s treatment.

The psychiatrist may also be crucial in optimizing the prescribed medications, manage a possible alcoholism diagnosis, and providing the appropriate psychotherapy for the patient.

Psychologists are crucial in providing appropriate psychotherapeutic treatment for the patient.

Psychologists can also link the patient to appropriate social support services for persons with alcoholism and those who face domestic abuse (Lopes et al., 2021).

Patient Education

·I would educate Maxine about menstrual abnormalities, the importance of monitoring her periods, and encourage iron supplements to prevent occurrence of anemia due to polymenorrhea and menorrhagia.

·I would also educate Maxine on hypothyroidism and hyperthyroidism and inform her on other symptoms associated with the two conditions.

·I would also educate her on MDD and anxiety symptoms and provide appropriate information she can use to manage the symptoms (Christensen et al., 2020).

·I would also provide nutritional advise to help improve her BMI to a normal weight and discourage her from heavy alcohol consumption.

·I would also educate her on available social support services who provide services to persons facing domestic abuse.