Family Medicine 12: Case Study

Family Medicine 12: Case Study

Discuss the questions that would be important to include when interviewing a patient with this issue.

When was the Last Menstrual Period? This is the date of the patient’s last menstrual period. With this information, the doctor can help asses whether it is a normal bleeding or abnormal bleeding. Normal bleeding is expected to occur after 28 days.

Have you been sexually active? Generally, a sexually active individual is at high risk of getting sexually transmitted infections, which could be the cause of the bleeding.

Are you using Oral Contraceptives? Oral contraceptives are hormonal drugs that tend to cause hormonal alterations in patients who use them. In effect, the changes usually cause bleeding.

Are you pregnant? This will help the doctor to know whether the condition is arising from a pregnancy complication such as threatened abortion, ectopic pregnancy, complete abortion, or postabortal trophoblastic disease (Motta& Vitale,2018).

Describe the clinical findings that may be present in a patient with this issue.

Are there any diagnostic studies that should be ordered on this patient? Why?

Some of the possible clinical findings include:

Low-grade fever

Tenderness of the abdomen

Abdominal pain

Irregular vaginal bleeding

The diagnostic studies include:

A pelvic ultrasound scan – this scan will help in assessing the pelvic organs and determining any pelvic inflammatory diseases.

Nucleic acid amplification tests (NAATs) – this test is vital in determining chlamydial infection.

 List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.

The primary diagnosis is dysfunctional uterine bleeding. In adolescents, the most common cause of vaginal bleeding is anovulation. This usually tend to arise due to non-cyclic production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH)( Critchley,2017)

Some of the differential diagnosis:

Chlamydial infection- typically, this bacterial infection is very prevalent among teenagers, especially those who are sexually active.

Vaginal ulcerations- this may result due to injury caused by foreign objects.

Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.

Pharmacological therapies – For dysfunctional uterine bleeding, the doctor first needs to determine the intensity of flow. A heavy flow causing anemia will need a prescription of iron pills. For persistent light bleeding, the doctor should recommend birth control pills. These pills help in achieving a hormonal balance within the body, thereby stopping the bleeding. In the case of chlamydial infection, the doctor will prescribe oral antibiotics such as Zithromax.

Tests – To determine whether the patient is anemic, the doctor needs to order a blood test. In case the patient is sexually active, chlamydia screening should be ordered.

A patient with very low hematocrit, that is, below 30, should be hospitalized and recommended for transfusion.

Patient education- the patient needs to be equipped with knowledge regarding the best nutrition. This should include iron-rich foods. Also, the patient needs to have an understanding of the hormonal changes occurring in the body that cause the condition she is experiencing. Finally, as a preventive measure, the patient should be educated on sexually transmitted infections and how to avoid them.

After the prescription of birth control pills, follow up visits should be arranged to assess the progress. Typically, the next appointment after the initial interaction should be 28 days later. Within this time, it is expected that there will be a hormonal balance, and the vaginal bleeding shall have stopped. Depending on the outcomes, the doctor will further prescribe the pills or opt for a different treatment plan (Motta & Vitale,2018).