What observations did you make during the physical assessment?

Subjective Ms.A, a female 32-year old woman who visited the clinic this morning complaining about heavy and painful bleeding during her menstrual cycle. Her periods are irregular and have not been for 6 months. The last period was 2 weeks ago. She claims to have no past history of sexually-transmitted infections. However, she has been experiencing pain during her sexual activity for the past two weeks.

Objective: Vital Signs: Blood pressure 120/80 mmHg, heart rate 80 beats per minute, respiratory rate 16 breaths per minute, temperature 98.6°F. General: There is a grimace of pain and discomfort on the face. Abdomen : Non-distended, soft, and not tender. Cervix healthy, normal appearance. The adnexa are not tender, but the uterus is.

Ms.A presents with menorrhagia and dyspareunia. The differential diagnosis may include endometriosis (adenomyosis), uterine fibroid, pelvic inflammation disease, or adenomyosis. Additional diagnostic testing is required to eliminate any underlying condition.

Plan:

1. You can order a pelvic ultrasonography to check for abnormalities, such as fibroids.
2. Anemia can be diagnosed by ordering a complete blood count.
3. Begin administering nonsteroidal analgesics (NSAIDs), to the patient, for pain control.
4. Patients should be educated on how to relieve symptoms using heat therapy or over-the counter pain medication.