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Chief complaint
“My periods have become really painful, and I’m having bad cramping throughout my cycle – not just during my period.”
History of present illness
Sarah P. is a 29-year-old Asian female presenting at her primary care provider, a Women’s Health Nurse Practitioner, with pelvic pain. She describes the pain as originating from deep within her pelvis. She says it is intermittent, and “dull and cramping,” worsening during just before and during menstruation. She ranks her pelvic pain during menstruation as an 8 out of 10, and says that taking Advil “helps a little.” She thinks the pain started “about six or seven months ago,” and states that the pain has gotten “progressively worse” since then. During the same time period, the patient has also experienced dyschezia, dysuria, and dyspareunia.
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Past medical history
- Nulligravidous
- Age of menarche: 12
- Length of menstrual cycle: 26 days
- Duration of menses: 7 days (described as “heavy”)
- First day of last menses: 11/2
- Current medications: cetirizine (Zyrtec), 10 mg PO daily; daily women’s multivitamin (Alive! brand)
- Allergies: penicillin, cats
Pertinent social history
- The patient is a horticulturist at the Franklin Park Conservatory, through which she is enrolled in an HMO
- She lives in Worthington with her partner of 7 years, and their two dogs. They plan to have children and have been trying to conceive for the last year.
- She denies smoking or drug use, and reports that she has stopped drinking while trying to conceive. Previously she estimates she had 3-4 drinks per week.
- The patient walks her dogs every day but otherwise does not exercise.
- She describes her diet as “fairly healthy,” but says she “probably eats too much salt.”
Pertinent family history
- Mother: 62 years, alive, dx cervical cancer (43 y/o), endometriosis (31 y/o)
- Father: 64 years, alive, dx HTN (38), COPD (55)
- Brother: 30 years, alive and healthy
Photo from https://www.healthtap.com/topics/pelvic-ultrasound
General Physical Exam/Vitals
- Height: 5’8”
- Weight: 130
- BMI: 19.8
- Temp: 98.3
- BP: 115/72
- RR: 16
Focused Physical Exam
- Abdomen:
- Bowel sounds present in all four quadrants
- No tenderness upon palpation
- External genitalia:
- Labia are soft, nontender and mostly symmetric; skin is intact
- Urethral orifice is midline, no inflammation, discharge, or lesions
- Vaginal introitus is midline and moist; no inflammation, lesions or fissures
- Internal genitalia:
- Cervix is firm, smooth, pink, midline, and angled slightly anteriorally
- Cervical mucous is clear, thin, and odorless
- Uterus is midline, pointing slightly anteriorally, pear-shaped, 6.5 cm long, with smooth, firm walls
- The posterior vaginal fornix is tender upon palpation, and a small, hard, tender nodule is palpable
The NP orders a pelvic ultrasound, which confirms the presence of small nodule in the posterior vaginal fornix, but does not reveal additional abnormalities.