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Chief Complaint (CC): A.P. is a 31-year-old Caucasian female presented to the clinic with the chief complains of 5 years of the irregular menstrual cycle, pelvic pain that started about a year ago with increased intensity and length for about a month, and$17.99
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Chief Complaint (CC): A.P. is a 31-year-old Caucasian female presented to the clinic with the chief complains of 5 years of the irregular menstrual cycle, pelvic pain that started about a year ago with increased intensity and length for about a month, and
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Chief Complaint (CC): A.P. is a 31-year-old Caucasian female presented to the clinic with the chief complains of 5 years of the irregular menstrual cycle, pelvic pain that started about a year ago with increased intensity and length for about a month, and acute onset of burning on urination started...
Initials A.P Age 31 Sex Female Race Caucasian Insurance Blue Cross Blue Shield
S.
Chief Complaint (CC): A.P. is a 31-year-old Caucasian female presented to the clinic with the
chief complains of 5 years of the irregular menstrual cycle, pelvic pain that started about a year
ago with increased intensity and length for about a month, and acute onset of burning on
urination started about 2 weeks ago. A.P. reported to live with her boyfriend and is sexually
active for last 5 years.
HPI: A.P is a 31-year-old female presented with the long history of the irregular menstrual cycle,
chronic pelvic pain, and new onset of burning urination. A. P. had her menarche at age 13 years
of age and her menstrual cycle was regular. Since last 5 years, her menstrual cycle has been
irregular. She reported having her cycle once every 2 to 4 month with heavy menstrual flow and
dysmenorrhea. She was started on the oral contraceptive pill for her abnormal menstrual cycle,
menorrhagia, and dysmenorrhea which she tried for about a year. It helped to regulate her cycle
but she gained weight abruptly and had mood change so she decided to stop it. After she stopped
taking birth control pill her symptoms came back. She hasn’t seen the OBGYN for 2 years. She
also reported few episodes of a headache and nausea and had done multiple home pregnancy
tests which have been negative. The last home pregnancy did four days ago was negative. She
also reported having intermittent pain in the pelvic region which has been going on for about a
year. She explains the pain as mild to moderate dull aching pain, rated 3-5 in the scale of 0-10,
around the pelvic and lower abdomen, worsened during and after sex. The Hot top bath helps her
to relax and relieve some of the symptoms. She reported to have increased frequency of pelvic
pain and new onset of burning on urination for last 2 weeks which she is worried about possible
infection or illness, therefore she decided to visit the clinic. She denies fever, frequency,
urgency, foul smell, flank pain, or local soreness. The burning sensation is so severe that she
, WOMEN’S HEALTH LATEST UPDATE.
needs to sit or run cool water after she voids. Drinking plenty of fluids and cool water makes her
feel better. She denied using other medical remedies to treat the symptoms.
Irregular menstrual cycle
Onset: 5 years ago
Location: vagina/uterus
Duration: Once every 2-4 months followed by dysmenorrhea and menorrhagia which last for 7 to
10 days.
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