Name:  

 Pt. Encounter Number:

Date: 

Age: 29

Sex: 

SUBJECTIVE

CC:  

“I’m here because of menopausal changes to my periods. Which I’m concerned may make me impotent and never get pregnant.” 

HPI:  

The patient is a 29-year-old female presenting with concerns about irregular menstruation and difficulty conceiving. She reports her periods have been irregular for the past 11 months after discontinuing birth control. She stopped the birth control pill to try to conceive. After discontinuation, her first period was absent for 8 weeks, followed by infrequent cycles every 2-3 months. Each period is described as light, lasting only 2-3 days. She reports a history of irregular periods starting at age 13, which led to her being placed on birth control. She also mentions a noticeable increase in facial hair (particularly on the chin and upper lip), which she waxes frequently, as well as increased acne and darkening of the skin under her arms and in the groin area. She has gained approximately 20 pounds over the past two years. The patient reports trying a progesterone pill 6 months ago, but it did not regulate her cycle.

Medications: None currently, previously used oral contraceptives and progesterone pills for menstrual regulation. 

Allergies: No known drug allergies.

Medication Intolerances: None.

Past Medical History: Menstrual irregularities since menarche at age 13.

• Previous use of birth control to regulate cycles.

 Chronic Illnesses/Major traumas: None reported.

 Hospitalizations/Surgeries

• None. 

Family History

• No history of diabetes, hypertension, heart disease, or thyroid problems in immediate family.
• No known family history of reproductive health issues. 

Social History

• Non-smoker, no alcohol use or illicit drug use.
• Lives with partner, employed as a teacher.
• No safety concerns. 

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General: Weight gain of 20 lbs over the past two years. No fever, fatigue, or night sweats. 

Cardiovascular: No chest pain, palpitations, or edema. 

Skin: Increased acne, darkened skin in axillae and groin. No rashes or lesions noted. 

Respiratory: No cough, dyspnea, or wheezing. 

Eyes: No visual changes, corrective lenses not needed. 

Gastrointestinal: No abdominal pain, nausea, vomiting, or diarrhea. 

Ears: No hearing loss, ear pain, or ringing in the ears. 

Genitourinary/Gynecological: Irregular menstrual cycles, light periods, attempting conception. Last pap was two years ago, normal results. No vaginal discharge. No history of sexually transmitted diseases (STDs). 

Nose/Mouth/Throat: No sinus problems or throat pain 

Musculoskeletal: No joint pain, back pain, or stiffness.

Breast: No dimpling, wrinkling, or discoloration of the skin. No skin retraction or nipple inversion noted. 

Neurological: No seizures, transient paralysis, or weakness.

Heme/Lymph/Endo: No excessive thirst or hunger. No known history of thyroid problems.

Psychiatric: No history of depression or anxiety.

OBJECTIVE

Weight: 170 lbs BMI: 28.3 (Overweight)

Temp:  98.6°F

BP: 122/78 mmHg

Height:  5’5”

Pulse: 76 bpm

Resp: 16/min

General Appearance: Healthy-appearing adult female in no acute distress. Alert and oriented, cooperative with a slightly somber affect initially but brightened later.

Skin: Brown, warm, dry, no rashes or lesions noted. Darkened skin in the axillae and groin areas.

HEENT: Head normocephalic, atraumatic. PERRLA, EOMs intact. No conjunctival or scleral injection. Ears clear, TMs pearly gray. Oral mucosa pink and moist, no lesions.

Cardiovascular: S1, S2 with regular rate and rhythm. Pulses 3+ throughout. No edema.

Respiratory: Clear to auscultation bilaterally. Symmetrical chest expansion.

Gastrointestinal: Abdomen soft, non-tender, obese, BS active in all four quadrants.  

Breast: Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary: No adnexal masses or tenderness. Cervix nulliparous, well estrogenized. No vulvar lesions. 

Musculoskeletal: Full ROM in all extremities, no joint swelling or deformities.

Neurological: Alert, oriented, no motor or sensory deficits noted. Gait normal.

Psychiatric: Cooperative, normal mood and affect.

Lab Tests

• Urinalysis (point-of-care test): nitrites and blood are present, but leukocytes are not.
• Urine culture: Done in the office and sent to the laboratory lab to wait for results.
• Wet prep: Information was collected in the workplace and sent through the lab until the results were ready.

Assessment 

Polycystic Ovary Syndrome (PCOS)

PCOS is a common condition affecting women in the child bearing age that manifests in different ways like delayed menstruation, obesity, acne, hair growth, and darker skin. The patient's periods have been erratic, more so since she discontinued birth control. Not long ago, they put on weight, and now their acne gets worse. These represent all symptoms of PCOS. Anovulation, or not ovulating, renders it harder to get pregnant because it makes periods happen less often. It is a sign of PCOS. It was also found that the person had hirsutism, meaning they had extra hair on their chin and upper lip, as well as darkening under their arms and in their thighs. According to Siddiqui et al. (2022), PCOS has many reasons, such as genetic and situational ones. Also, insulin resistance is often linked to this condition, which can make obesity and periods that fail to appear on time worse.

Hypothyroidism

The person may gain weight, have periods that don't come on time, and see changes in their skin. These are all signs of hypothyroidism, a medical condition whereby the thyroid gland doesn't work properly. Thyroid hormones are very important for controlling metabolism and ensuring overall health during pregnancy. Insufficient amounts of these hormones can mess up the menstrual cycle, causing periods to come and go or even amenorrhea (Itriyeva, 2022). Less biological exercise can lead to weight gain, which usually happens slowly. Due to poor circulation and slower skin growth, hypothyroidism can also cause changes in the skin, like it getting dry and darker. Finding out if hypothyroidism is the reason of the patient's symptoms would require a thyroid function test that measures blood amounts of thyroid-stimulating hormone (TSH) and free T4.

Hyperprolactinemia

Hyperprolactinemia is an illness where there are too many prolactin levels in the body. Because it stops ovulation, it can cause periods to be unpredictable and impotence. Prolactin is responsible for breastfeeding, but excessive levels of it may inhibit the secretion of gonadotropin-releasing hormone (GnRH). This ceases the generation of luteinizing hormone (LH) as well as follicle-stimulating hormone (FSH), which are both needed for ovulation to happen normally (Papadakis et al., 2020). High levels of prolactin may be to blame for the patient's irregular periods and failure to get pregnant. High levels of prolactin usually lead to anovulation and infertility. There are other signs that hyperprolactinemia can cause, such as galactorrhea, which is a condition where you make milk without trying to. In this case, though, this wasn't said. A blood prolactin test could assist to confirm this diagnosis and figure out the next step in treatment.

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Final Diagnosis:

Hypothalamic Amenorrhea 

Hypothalamic amenorrhea happens when the hypothalamus is affected by things like stress, big fluctuations in weight, or intense exercise. The hypothalamus handles chemicals that are required for pregnancy as well as menstruation. Period problems, light bleeds, and challenges getting conceived after discontinuing birth control are all signs that the brain fails to transmit chemicals properly. According to Podfigurna & Meczekalski (2021), not ovulating, gaining weight, and other symptoms like acne and face hair growth may be signs of an underlying chemical imbalance that is affected by the hypothalamus. Though Polycystic Ovary Syndrome (PCOS), hypothyroidism, and hyperprolactinemia were thought of as possible causes, the patient's history of irregular periods after stopping birth control, no ovulation, and no clear cysts on the ovaries point to a hormonal problem at the central level rather than problems with the ovaries or thyroid.

Plan

Medications:

• Oral contraceptive pills (OCPs) or a combination of estrogen and progestin therapy to regulate the menstrual cycle.
• Metformin could be considered to help manage insulin resistance, commonly seen in PCOS patients.

Non-pharmacological recommendations: Weight management through a balanced diet and exercise plan. Weight loss may help regulate periods and improve fertility.

Diagnostic Tests:

• A scan of the pelvis to look for ovarian cysts.
• Levels of serum testosterone, LH/FSH, fasting glucose, and insulin to confirm PCOS.
• Levels of TSH and prolactin to rule out problems with the pituitary gland and thyroid.

Patient Education: The patient was taught about PCOS, how it can cause infertility, and how important it is to control their weight. We talked about different fertility treatments that could help people get pregnant.

Health Promotion: Encouraged lifestyle changes, including a healthy diet and regular physical activity.

Referrals: Refer to endocrinology or reproductive endocrinology for further evaluation and management of PCOS-related infertility.

Follow-up: Schedule follow-up in 3 months to assess the efficacy of the treatment and lifestyle modifications. Further evaluation of fertility status may be necessary.