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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  
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