Consult
from: Dr. Raymond
April
M Driesse is a 24 year old. Caucasian female Patient has a history of
PCOS and severe dysmenorrhea. Dysmenorrhea happened since
childhood. PCOS diagnosed in 2012.
Addison's
disease diagnosed at age 11 on Cortef and floricef.
H/o
DVT/PE - Hypercoagulable.
Chronic
back pain see pain management.
For
the past year, pt c/o constant pelvic pain. Much worse during period.
H/o
RPL x 6.
Obstetric
History
G8
P2 T0 P2 A6 TAB0 SAB6 E0 M0
L1
(This means Gestation: 8 (I have 1 living child, 1
stillborn, and 6 miscarriages, they do not count chemical pregnancies during
this. P: This means Para, The Birth of Viable Babies, that is 20 weeks onward
so I have Gabriella and I have my stillborn. T: This means Term. Gabriella
was born 36 weeks, so she was not term, and my stillborn was at 20 weeks, so
Term is 0 for me. P: This P signifies Pre-Term Births. This number is 2 for
me, because my stillborn was at 20 weeks and Gabriella was 36 weeks. TAB
means Theraputic Abortion, which is 0 for me, because I've never had any
abortions. SAB is Spontaneous Abortions, or in my case, miscarriage. This is
a fancy/offensive way of saying a woman has had a miscarriage. For me, I have
had 6, and I've had 2 chemical pregnancies which were miscarriages but for
whatever reason they do not count those. E means Ectopic, which for me is 0.
M stands for Molar Pregnancy which for me is 0, and L stands for Living,
which for me is 1)
Menstrual
Hx:
Menarche:
7 years old
Cycle
length: 32-35 days
Duration:
6 days
Flow:
heavy to light
Tonsillectomy Hx - 1999
|
D and C Diagnostic (x2)
|
History
of present illness:
Characteristics
of the pain are as
follows:
Chronicity:
Onset: since she was 7 years old.
Location:
suprapubic and low back pain without radiation
Quality:
dull and sharp
Quantity:
10/10 in intensity during mense. 7/10 during intercourse
Aggravating
factors: none
Alleviating
factors: heating pad
Associated
symptoms: no
Menarche?
7
Are
you still having menstrual periods? Yes
If
yes: PERIOD REGULARITY: regular q 28-30 days, FLOW CHARACTERISTICS: heavy,
bleed through protection and length of flow 6 days, DYSMENORRHEA: throughout
menses, CYCLIC SYMPTOMS: pelvic pain, HORMONE REPLACEMENT: Has tried
Micronor, Lo-Orval and Other OCP in past.
Do
you pass clots? Yes
April M Driesse is a 25 year old female with severe dysmenorrhea.
We
went over several options both surgical and medical.
Patient
at first interested in medical treatment with lupron but later decide to have
surgery.
She
will contact her endocrinologist and hematologist for recommendation for
treatment prior to her surgery.
Since
she has quite significant pelvic muscle tenderness, I recommend she starts
pelvic floor PT.
Order
placed.
R/b/a
of the procedure discussed. Patient would like to proceed with surgery.
I
discuss with her that due to her medical problems, I think it is appropriate
to try medical management first. However, patient declines medical
treatment and only interested in having surgery.
Julie
Tan, MD
|