History

Full Name: A.R. 

Age: 27 years

Date & Time: June 26, 2024

Location: Woodhull Medical Center

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Public transportation

CC:

“I’m here to discuss the results of my pelvic ultrasound.”

HPI:

A.R. is a G2P2002 female, LMP 09/2023, presents to the outpatient clinic today to discuss the results of her pelvic ultrasound. Pt originally presented to the clinic in 03/2024 with complaints of not having menstruation since 6 months prior to her visit. Pt says she never experienced anything like this and prior to this time she has had regular menstruation, besides for when she was pregnant. Pt said that she was not sexually active and the pregnancy test in the office was negative at the time. Pt denied having acne, hirsutism or deepening of her voice. PCOS labs were sent out. This included LH, FSH, TSH, A1C and prolactin which were all within normal limits. She was put on a Provera challenge where she took Provera 10 mg daily for 10 days. Pt experienced withdrawal bleeding after the challenge, which further indicated a diagnosis of PCOS. At the same time pt was sent for pelvic ultrasounds, both transabdominal and transvaginal. Pt returns today to get the results.

Pt was informed that on ultrasound there is endometrial thickening (~1.6 cm in diameter) with multiple, small cystic spaces. Pt admits that she still is not having regular periods since after the Provera challenge. Pt denies abnormal vaginal discharge, pelvic pain, unexplained weight loss, dysuria or weakness in the lower extremities. 

Medical History:

• Denies

Medications:

• Denies

Surgical History:

• No past surgical history.

Allergies:

• No known drug/food/environmental allergies

Ob/gyn History:

• NSVD x2
• Last pap 3/13/24- neg
• Denies history of STDs

Family History:

• Mother: Alive age 50, good health
• Father: Estranged
• 2 children (aged 5 and 6): alive and well
• No known family history of cancer or cardiac disease

Social History:

• Smoking: Denies
• Alcohol: Denies
• Illicit drug use: Denies past or current use
• Marital History: Single
• Language: English
• Occupational History: Works in a restaurant
• Travel: No recent travel
• Home situation: Lives at home with family
• Sleep: Endorses adequate sleep
• Exercise: Does not exercise
• Diet: Reports diet heavy in carbs and proteins. 
• Caffeine: Denies caffeine use 

ROS:

• General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies epistaxis, nasal congestion, sore throat, head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, discharge, bleeding gums.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, or pain.
• Pulmonary: Denies cough, hemoptysis, dyspnea, wheezing, cyanosis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, vaginal discharge, dysuria and malodorous urine.
• Menstrual/Obstetrical: G2P2002, LMP 09/2023; not currently sexually active 
• Musculoskeletal: Denies back pain, muscle pain, joint pain, arthritis and joint swelling.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric: Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, obese female in no apparent discomfort. Appears stated age of 27. Neatly groomed, alert and oriented x3.

Vital Signs: 

• BP: 122/80 mm Hg
• R: 18/min, regular rate and rhythm, unlabored
• P: 76 beats per minute, regular rate, rhythm and amplitude 
• T: 98.6 degrees F (temporal)
• Height: 60 inches Weight: 183 lbs 4.8 oz BMI: 35.8

Thorax and Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam:

• Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants. Nontender to palpation and tympanic throughout, no guarding or rebound noted. 

Pelvic Exam:

• Normal female external genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix multiparous, pink and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Differential diagnosis:

• Polycystic ovarian syndrome
  • PCOS is one of the most common causes of abnormal uterine bleeding and is more common in obese females. Additionally, the fact that the patient had withdrawal bleeding after the Provera challenge indicates that she has proper levels of estrogen, but never has a drop in progesterone (naturally) which is common with PCOS. The fact that her labs were within normal limits is not uncommon in pts with PCOS. The pelvic ultrasound findings of endometrial thickening and multiple cystic spaces are consistent with PCOS.
• Endometrial hyperplasia
  • The ultrasound shows endometrial thickening (~1.6 cm). This could be due to prolonged anovulation leading to unopposed estrogen stimulation, which is common in PCOS. Endometrial hyperplasia can increase the risk of endometrial cancer, especially if left untreated.
• Hypothyroidism
  • Although TSH was within normal limits previously, thyroid dysfunction can present similarly with menstrual irregularities and weight gain. Consider re-evaluation if symptoms persist or new symptoms arise.
• Endometrial cancer
  • Given the significant endometrial thickening, especially in the context of prolonged amenorrhea, this should be ruled out, particularly if endometrial hyperplasia is confirmed on biopsy. This is unlikely due to her age.

Assessment:

• 27 year old obese female G2P2002 with 9 months of amenorrhea presents today for results of her pelvic ultrasound. Pathologic findings of the ultrasound were discussed along with her likely clinical diagnosis of PCOS. All parts of her physical exam were within normal limits and there were no new labs to look over. Her presentation is most likely due to PCOS with endometrial thickening due to that. 

Diagnosis:

• PCOS
• Pending results

Plan:

• PCOS
  • Begin OCPs vs. surgical treatment once endometrial biopsy results return
  • Educated regarding the importance of weight loss, healthy diet and exercise regimen
  • Educate regarding the importance of OCPs and the endometrial protection it provides
• Endometrial thickening
  • Endometrial biopsy
  • Return to clinic in 2 weeks for results