Jessica, a 38-year-old white female, has had three term births and one first-trimester spontaneous abortion (G4P3013). Her third child was delivered via cesarean section and she underwent tubal sterilization at that time.
She presents complaining of a 6-month history of fatigue. She reports no other symptoms, no recent illness or change to her physical or emotional health, including no depression or significant stress that might account for her fatigue. She does not smoke and uses alcohol only in social situations.
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You order a complete blood count (CBC) with platelets, which reveals a hemoglobin level of 10.1 g/dL and hematocrit of 29.8; other RBC indices are consistent with iron deficiency. WBCs and platelets are within normal ranges. You also check her thyroid-stimulating hormone level, which, at 1.8 mIU/L, is within normal limits.
You inquired about her menstrual periods, she reports that they are regular, with bleeding lasting 7 to 9 days. She typically uses super-absorbent tampons, changing them approximately every two hours in the first couple of days of her period. She also relies on pads for backup during her days of heavier flow. She has noticed that she sometimes passes quarter-sized clots. While discussing these details, it becomes clear that Jessica has had heavy periods throughout her reproductive life, but she had never sought medical help because she had accepted her periods as a normal aspect of her life.
Jessica’s medical history is remarkable for hypertension and she currently takes 25 mg a day of hydrochlorothiazide. Her only other medication is a daily multivitamin. Her surgical history includes a tubal ligation. She reports no allergies.
She reports no intermenstrual or postcoital bleeding and is sexually active with only her husband. There is no family history of breast, ovarian, colon, or uterine/endometrial cancers and no history of abnormal Pap tests or positive screens for sexually transmitted infections.
On physical examination, Jessica is a well-developed, obese white female in no apparent distress. Blood pressure is 138/87, pulse 78, temperature 98.9°F, height 5’6”; weight 267 pounds, BMI 43.09 kg/m2. Aside from the obesity, there are no other relevant nonpelvic physical findings.
Her pelvic exam reveals no vulvar or vaginal lesions; a small amount of dark blood is present in the vault. There is no cervical motion tenderness or cervical lesions. Her uterus and adnexal structures are difficult to palpate because of her abdominal girth, though the uterus does not appear to be enlarged and there are no pelvic masses palpated.
With the above information, construct the subjective and objective data in a SOAP Note format.
What is your assessment of this patient?
What are your thoughts on the treatment plan of this patient?
Is there any other information that you would obtain to assist you in determining treatment options?
Which guidelines would you consult?