Chief Complaint: “I’ve been having heavy, painful menstrual bleeding every month for the past 4 years”
History of Present Illness: 46 y/o G10P4154 F presents today for heavy, painful menstrual bleeding x4 years. Patient states that symptoms began when she was diagnosed with fibroids four years ago. She states that her menses “have always been heavy”, lasting approximately five days. Her menses are now 26-28 days apart, lasting 7-8 days. She admits to using 12 medium sized sanitary napkins on the heaviest day of her menses. She endorses weakness during this time and admits to requiring two transfusions in the past as well as iron therapy due to her heavy menstrual bleeding. Patient states that she experiences severe, dull and achy, LT sided cramps which have been present for 6 years. As per patient, these cramps begin shortly before her menses and last throughout the entire cycle. She reports using heating packs and ibuprofen with minimal relief, and rates her pain a 10/10 in severity. LMP: current. Patient denies intermenstrual bleeding, postcoital bleeding, recent weight loss, dysuria, hematuria, urinary urgency, urinary frequency, abnormal vaginal discharge, excessively rough intercourse, or trauma.
Differential Diagnosis:
- Heavy menstrual bleeding secondary to uterine fibroids
- Adenomyoma
- Endometrial hyperplasia/malignancy
- Von Willebrand disease
Medications
Genvoya 150 mg daily with food
Aspirin 81 mg chewable tablet
Denies OTC or herbal supplement use
Past Medical History:
Asthma, not controlled
HIV positive, viral load undetectable
HPV positive on anal pap
Hx of CVA at age 30
Immunization History:
Immunizations are up to date
Gardasil incomplete; last dose was due March 2023
Preventative Medicine Screening:
Mammography (contrast enhanced) – (11/20/2023) low suspicion for malignancy. LT breast densely enhanced, mass measuring 25×16 mm. RT breast mass measuring 13×10 mm, probably benign. Patient underwent LT breast lumpectomy on 11/22/2023. Patient was due for mammography early August 2024.
Pap Smear – (10/27/2023) negative for intraepithelial lesion or malignancy. No HPV cotesting performed at this time.
Bone Density/DEXA Scan – not due for screening
Colonoscopy – not due for screening
Dental – N/A
Ophthalmologic – N/A
Past Surgical History:
C-section x1 performed at Mount Sinai
Cholecystectomy performed at Mount Sinai
Hysteroscopy D&C performed at Woodhull Medical Center
Umbilical Hernia repair performed at Mount Sinai
Right inguinal hernia repair performed at Mount Sinai
LT eardrum surgery performed at Mount Sinai
RT foot surgery performed at Woodhull Medical Center
Allergies:
Latex, reaction: hives
Peanuts, reaction: shortness of breath
Pitocin, reaction: unknown
Family History:
Maternal cousin with breast cancer at 56, alive and in chemotherapy
Maternal uncle with colon/prostate cancer at unknown age, unknown if alive
Sister with ovarian cancer at unknown age, alive, unknown if in chemotherapy
Other family members with lymphoid cancers, unknown
Social History:
N.D. is a 46 y/o F living in Flushing Queens
Habits – denies smoking or alcohol use. Admits to marijuana use.
Travel – no recent travel
Diet – patient reports eating frequent meals during the day with limited vegetable intake
Exercise – patient reports minimal daily exercise
Sleep – reports some nights of interrupted sleep, some nights are uninterrupted
Safety measures – patient practices seatbelt safety
OB History:
- G10P4154
- Four children carried to term
- 5 abortions; 4 living children
GYN/Sexual History:
Menarche: age 12
Menstrual Cycle: regular and heavy; 26-28 days apart, lasting 7-8 days
LMP: current (09/04/2024)
Sexually active with 1 male partner
Contraception: none
STD History: HIV positive, no history of other STDs
Review of Systems:
General: Reports weakness during menses. Denies fever, chills, night sweats, fatigue, loss of appetite, recent weight gain or loss
Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution
HEENT: Denies headache, vertigo, head trauma, unconsciousness, coma, use of contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia, deafness, pain, discharge, tinnitus, use of hearing aids, nasal discharge, epistaxis, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures
Neck: Denies localized swelling/lumps, stiffness/decreased range of motion
Breast: Denies lumps, nipple discharge, pain
Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND
Cardiovascular system: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur
Genitourinary: Denies frequency, urgency, incontinence, dysuria, nocturia, oliguria, polyuria
Sexual history: as per GYN/Sexual History
Menstrual and Obstetrical: date of last normal period: 4 years ago, menarche: age 12, interval between periods 26-28 days, duration and amount of flow 7-8 days, 12 medium sized pads/24 hours. Admits dysmenorrhea, menorrhagia, premenstrual symptoms: abdominal pain. Denies postcoital bleeding, vaginal discharge, dyspareunia, menopause.
Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness, arthritis
Peripheral Vascular System: Denies intermittent claudication, coldness of trophic changes, varicose veins, or peripheral edema, color change
Hematologic System: Denies easy bruising or lymph node enlargement
Endocrine System: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism
Nervous System: Reports hx CVA at 30. Denies loss of consciousness, ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)
Psychiatric: depression/sadness/anxiety
Vital Signs:
Temperature: 97.8 degrees Fahrenheit
O2 Sat: 100% on room air
Height: 65 inches
Weight: 62.6 kg
BMI: 22.96 kg/m2
Respiratory Rate: 18
Heart Rate: 60 bears per minutes
Blood Pressure: 100/72 RT arm, seated
Physical:
General: Patient appears clean & well groomed, alert & oriented to time, place, and person. Has good posture and appears to be a reliable source of information. Appears stated age and appears to be mildly uncomfortable.
Skin/Hair/Nails: skin is warm and moist, and non-icteric, no lesions noted. Cannot visualize hair because patient is wearing a wig.
HEENT: Head is normocephalic, atraumatic, and non-tender to palpation. Face is symmetrical with no signs of drooping, swelling, or trauma. Eyes are symmetrical OU, conjunctiva is white. Bilateral ears are symmetrical and appropriate in size without lesions, masses, or trauma on external ears. The nose symmetrical without masses, deformities, trauma, or discharge. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema noted. Pharynx is non-erythematous, uvula is midline.
Neck, Thyroid, and Lymph Nodes:
The trachea is midline without masses or scars. The thyroid is consistent in size and shape and non-tender to palpation. Evaluation of lymph nodes deferred.
Abdomen:
Abdomen is soft and non-tender to palpation. No guarding or rebounding noted. Pfannenstiel incision scar well-approximated and well-healed without any evidence of appreciable masses around or underneath it.
Breast Exam:
Deferred
Genitalia:
External genitalia without erythema or lesions. There is active, brisk vaginal bleeding noted. No clots or tissue are visible. Cervix appears closed and without lesions or trauma. No cervical motion tenderness noted. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.
Rectal:
Deferred
Peripheral Neurologic Exam
No atrophy, tics, tremors, or fasciculation. Gait steady with no ataxia. Strength and sensation intact.
Mental Status Exam
Patient is well appearing, good hygiene and neatly groomed. Patient is alert and oriented to name, date, time, and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory, and attention intact.
Peripheral Vascular Exam
The extremities are normal in color, size and temperature. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted.
MSK Upper and Lower Extremity
No soft tissue swelling/erythema/ecchymosis/atrophy/or deformities in bilateral upper and lower extremities. FROM of all upper and lower extremities bilaterally.
Imaging:
Image not available Pelvic U/S performed at Mt. Sinai on 07/08/2024
Indication: LLQ pain, concern for torsion
Technique: transabdominal and pelvic ultrasound
Comparison: pelvic ultrasound on 08/30/2016
Findings:
- Uterus: 9.9 x 5.5 x 7.4 cm, anteverted in configuration. Numerous fibroids present. sample fibroids measuring 2.4×2.3×1.9 cm, second measuring 1.5×1.6×1.9 cm, and smaller fibroid measuring 0.7×0.8×0.8 cm.
- Endometrium: 0.2 cm in double layer thickness
- Right Ovary: 3.0 x 1.5 x 1.4 cm. 3.2 mL. Normal. Adnexal cys measuring 1.2×1.0x0.5 cm. Doppler color flow and spectral analysis demonstrates normal arterial and venous waveforms.
- Left Ovary: 2.7×1.6×1.7 cm. 4.0 mL. Normal. Doppler floor flow and spectral analysis demonstrates normal arterial and venous waveforms.
- Free Fluid: none
Assessment:
46 y/o G10P4154 F presents today for heavy, painful menstrual bleeding x4 years. Transabdominal and pelvic ultrasounds reveal the presence of multiple small fibroids. Patient has extensive family history cancers, including GYN cancers. Endometrial biopsy required before determining best course of management.
Plan:
Return after menses have ceased for endometrial biopsy
Follow up in clinic to discuss results & definitive management (patient would like to undergo hysterectomy but unsure if partial or total)
BRCA testing
Tranexamic acid to temporarily improve heavy menstrual bleeding; patient says she has adverse effects associated with OCPs
Arianne Diaz (she) on 
