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CC: “Longer and heavier periods with horrible cramps”

HPI: Sarah is a 46 yo, married W/F who presents with C/O longer and heavier periods. She is a G3P3003, periods are regular, but have become increasingly heavier and longer over the last 6 months. Periods are every month and now last as long as 9-10 days with heavy flow the first 4 days with quarter size clots or larger and horrible cramps. She is not currently bleeding. Her menses prior to this was every month x 5-6 days with mild cramps, normally relieved with Midol and dime size clots. She has tried 2 midol every 8 hours with little relief of her cramps. She experiences bloating, wt gain, and breast tenderness before the onset of her periods. She uses condoms for birth control consistently. She also has been tired for the last 4 months. Her last Pap, HPV and mammogram were negative 3 months ago. LMP 2 weeks ago x 10 days with quarter size clots and horrible cramps. Menarche at age 12 and periods have been normal until 6 months ago.

PMH/PSH: SVD x 3, Tonsillectomy

FH: Mother-hypothyroidism

Meds: Caltrate 500mg bid

Allergies: None

Social Hx: In a monogamous relationship with husband of 25 years. Denies smoking, ETOH or drug use.

PE:

VS: BP sitting 118/74 P- 74, Lying 116/70 P- 76, standing 114/72 P- 78, RR 20 HT: 5’3” Wt: 124 BMI: 22

Lungs: Clear B/L, no wheezes, rhonchi, rales, or crackles.

Heart: RRR – good S1 and S2. No S3 or S4, murmurs, rubs, or gallops.

Abdomen: + BS x 4 quadrants. No masses or tenderness. No hepatomegaly.

Pelvic exam: External genitalia – normal without lesions or erythema. Vagina – pink with minimal white, creamy D/C. Cervix – no lesions, NT, no blood or brownish D/C from os. Uterus – AV, small, smooth, mobile and NT. Adnexa – No masses or tenderness.

Office hemoglobin: 9.0%

#1. What is her diagnosis?

#2. What information you would like to obtain more from this pt?

#3. What test or diagnostic test would you order?

#4. What the treatment would you give her?

#5. What education or patient instructions to give to this pt?