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Assignment: Case Study of a Patient with Heavy Menstrual Periods and Pelvic Pains

Assignment: Case Study of a Patient with Heavy Menstrual Periods and Pelvic Pains

 

The preferential diagnoses for this patient are varied. They include pregnancy, fibroids, abortion, adenomyosis, endometriosis, bleeding disorders, ectopic pregnancy, pelvic inflammatory disease, perforation, and endometrial cancer (Norwitz et al., 2019). Ultrasound is considered as the first line of radiological imaging that is used to evaluate the location of intrauterine device in patients with mal-positioned IUDs, abnormal bleeding, and pelvic pain (Casanova et al., 2018). Based on the symptoms that client has presented with, the use of ultrasound is an effective method for evaluating the location of IUD. There is a high likelihood that the IUD might be mal-positioned since the nurse cannot locate its strings (Nowitzki et al., 2015). A positive evaluation of the location of the IUD will be followed by its removal under ultrasound or hysteroscopic guidance. The IUD might not be located using ultrasound. Other methods such as CT scans can be utilized. However, they are secondary methods of locating it. Therefore, the risks of perforation are increased with delayed management.

Further assessment will include checking for parlor, palpating for any abdominal masses, checking for capillary refill, and taking

Assignment Case Study of a Patient with Heavy Menstrual Periods and Pelvic Pains

Assignment Case Study of a Patient with Heavy Menstrual Periods and Pelvic Pains

arterial blood gas analysis. History taking will focus on aspects such as alleviating and precipitating factors for bleeding, pregnancy history, past as well as present illnesses, surgeries, any use of medications, history of bleeding disorders, and menstrual cycle. Diagnostic studies that I will obtain include complete blood count, bleeding time, thrombin and prothrombin time, ultrasound, hysteroscopy, and magnetic resonance imaging if ultrasound does not yield conclusive results.

 

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The health education will focus on the investigations that are required, their purpose, the medications to be used, their side and adverse effects, and procedures that might be employed to treat her condition. It also focuses on the types of diets to eat; the need for adequate rest, and complications that the patient should report if they occur (Magowan, Owen & Thomson, 2014). I will develop priority needs of the patient and use them to develop plan of care. I will start by ensuring that the physiological needs of the patient are met first. The interpersonal collaborations that are needed included referring the patient to a gynecologist, general doctor for treatment of her high blood pressure and high BMI.

36 year-old Hispanic woman presents to clinic with complaints of heavy menstrual periods and pelvic for the past 3 years since getting the “10-year IUD”. Her blood pressure today is 152/94 and her BMI is 46. She would like to have the IUD taken out and she would like to know what she can do for the heavy bleeding. During your pelvic exam, you are unable to palpate any IUD strings and the patient’s uterus seems enlarged and boggy. She is also significantly tender with the bimanual exam.

Develop a list of differential diagnoses for this particular patient.

Consider each scenario regarding the IUD (locating via ultrasound and NOT locating via ultrasound ). How each scenario affect the management of this woman?

What further assessment, history, and diagnostic studies will you obtain?

How will you provide counseling specific to this patient’s needs and condition?

What can you do for this patient today to develop a plan of care regarding her specific problems?

Discuss interprofessional collaboration(s) you will consider

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