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Pelvic Pain

Content type
User Generated
Subject
Nursing
School
Miami Regional University
Type
Homework
Rating
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SUMMER MSN 6150
700 South Royal Poinciana Blvd
Miami Springs, Florida 33166
Encounter date: 7/9/2020
Patient Initials: A.M Gender: Female__________ Transgender ____ Age: 30 years
Weight: 169.6lb Height: 69.7” Pregnant: N/A Gestational Age: N/A
Last US Date: 17/9/2020
Chief Complaint: “I have had on and off stomach pain for five years now.”
HPI: A. M is a 30-year-old Caucasian female presenting to the medical office with the complaint
of been having on and off stomach pain for years now. According to the patient, the problem has
persisted, especially at her lower abdomen, and tends to change. Occasionally, the pain
intensifies to 8/10 and sometimes disappears altogether. In her report, it has been five years since
the problem started; however, nothing much happened to inflict the pain. Instead, the pain
continues to get worse. Even though she never feels the pain all the time, it occurs once a month
with a severe pack pain. She now uses ibuprofen to manage her pain. According to A.M, her pain
always worsens when having her periods and having sexual intercourse with her husband.
Unfortunately, they have never got pregnant for two years now, and would sometimes lack the
urge for sex, especially when under this pain. A.M also reports current episodes of fatigue,
maybe due to the stressful desire to become pregnant. Meanwhile, the patient denies fever.
Menstrual history: Monthly, denies bleeding or clot.
Age at menarche: 9 years. Last menstrual period: 2 weeks ago
Menstrual pattern: Monthly, after every four weeks Cycle length: 28 days.
Duration of flow: 8 days Amount of flow: The patient is unsure, but would change
the sanitary towels every two hours. Bleeding pattern: Denies bleeding or clot.
Associated pain (dysmenorrhea): Denies
Breakthrough bleeding: Denies
Pre menopause/menopause: No
Vasomotor symptoms: No
Hormone replacement therapy: No
Contraception: No Current method; satisfied with the method? N/A

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SUMMER MSN 6150
Previous methods, including complications, reasons discontinued? Denies
Cervical and vaginal cytology: Five months ago
Most recent Pap smear result: Normal
History of abnormal Pap smears? Denies
History of sexually transmitted infections: Denies
Vaginitis? Denies
History of pelvic inflammatory disease? Denies
Any difficulty conceiving in the past? Denies
Sexually active: Yes, with her husband.
History of sexual abuse or sexual assault? Denies
Obstetric history:
G 0
T 0
P 0
A 0
L 0
Describe any maternal, fetal, or neonatal complications?
The patient and the husband have been trying for two years to get pregnant, but they have not yet
succeeded.
Allergies (Drug/Other): None
PMH: The patient denies any history of a chronic medical condition.
Current or past illnesses: Pelvic pain, barrenness.
Hospitalizations: Never
Past surgical history: Denies
Current Meds: Ibuprofen for her pain management.
Family Hx: The mother died at 60 years of fibroids in the uterus. The father died at 80 years of
diabetes and leukemia.

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700 South Royal Poinciana Blvd Miami Springs, Florida 33166 Encounter date: 7/9/2020 Patient Initials: A.M Gender: Female__________ Transgender ____ Age: 30 years Weight: 169.6lb Height: 69.7” Pregnant: N/A Gestational Age: N/A Last US Date: 17/9/2020 Chief Complaint: “I have had on and off stomach pain for five years now.” HPI: A. M is a 30-year-old Caucasian female presenting to the medical office with the complaint of been having on and off stomach pain for years now. According to the patient, the problem has persisted, especially at her lower abdomen, and tends to change. Occasionally, the pain intensifies to 8/10 and sometimes disappears altogether. In her report, it has been five years since the problem started; however, nothing much happened to inflict the pain. Instead, the pain continues to get worse. Even though she never feels the pain all the time, it occurs once a month with a severe pack pain. She now uses ibuprofen to manage her pain. According to A.M, her pain always worsens when having her periods and having sexual intercourse with her husband. Unfortunately, they have never got pregnant for two years now, and would sometimes lack the urge for sex, especially when under this pain. A.M also reports current episodes of fatigue, maybe due to the stressful desire to become pregnant. Meanwhile, the patient denies fever. Menstrual history: Monthly, denies bleeding or clot. Age at menarche: 9 years. Last menstrual period: 2 weeks ago Menstrual pattern ...
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