WOMEN'S HEALTH CASE STUDIES
(ER'BODY) QUIZZES WITH RIGHT
ANSWERS.
Case 1
28 y.o. patient has change in menses consisting of cycles lasting 10 days. She is using 7-8 super pads per
day, and clots are nickel sized. Improves at night.
Vitals: Wt: 170
Ht: 5'8"
Pulse: 88
BP: 128/74
RR: 16 ANSWER : -My Initial Assessment:
-Her vitals are stable, i would still compare to a baseline if there is one for comparison for changes. Do a
pregnancy test. Is she anemic? Check her Hct.
-Her BMI is 25.8, she is overweight. I would ask her about any recent weight changes to see if that has
had an effect on her cycle?
-Menstrual bleeding assessment based on soaking 7 super pads per day with nickel sized clots = 414
points per day or 1410 points per week. She falls under the category of Menorrhagia/Heavy Menstrual
Bleeding. I would ask her about what changed about her period: Is it the same amount of bleeding but
for more days, or heavier bleeding for the same amount of days? Is this the only cycle that has been
different like this, or how many like these has she had now? If this is the first one, could she be pregnant
and she is having a miscarriage? Is she having lots of pain with menstruation?
-I would ask her if she is taking contraception? Birth Control, in all its forms usually makes periods lighter
and shorter. If she is starting a new birth control method, is it causing her to have menorrhagia.
-I would change her birth control based on the information that she provides if what she is newly on
isn't working for her.
-Could she have any of the PALM-COEIN causes of Menstrual bleeding.
-Physical Exam and palpation for fibroids or adnexal masses or tenderness and transvaginal U/S to see
fibroids or endometrial lining abnormalities.
-IF the bleeding continues: I would recommend endometrial biopsy to look for hyperplasia.
,-IF endometrial biopsy is normal, are her hormone levels normal? If her testosterone is high and her
periods are very heavy and irregular, then could she have PCOS?
-Continue to R/O causes on the PALM-COEIN list.
-Improvement with the bleeding at night: Im not sure what that could be except: except n
Case 2: A 56-year-old patient comes to the urgent care on Saturday. She is concerned because her
period started again this week. It was light and short but she had to use a full pad for 2 days and had
cramps. She had thought she was done with menopause 2 years ago.
This pt is using urgent care because she has no primary.
Vitals:
Weight: 230 Height: 5'7''
BP: 140/84 Pulse: 94 Respirations: 14 ANSWER : -Meds: Women's Silver OTC daily. She sometimes
remembers to take her calcium and vitamin D.
Family Hx: There is no family history of any "female cancers."
Social: No tobacco/EtOH use; has not been sexually active since her husband was killed in a work
accident 5 years ago.
Pelvic exam: reveals normal genitalia. She has a grade 1 cystocele that does not cause symptoms. When
asked she reports delivering 2 vaginal children, both 9 lbs. Vagina is somewhat dry with flattened rugae.
There is no blood in the vault. Cervix is parous and closed, non tender. Uterus is retroverted. It is difficult
to palpate true size due to patient's habitus however it does feel enlarged, possibly 12-14 weeks size.
She is non tender during exam. Adnexa are non palpable.
This patient has no insurance.
You discuss with her that you would greatly like to obtain a biopsy due to her length of time from
STRAW stage 0, her sudden menses, her enlarged uterus, and her risk factor for endometrial cancer
(age, obesity, and post menopausal status). This patient is able to have 1 test done at this time.
,Endometrial Biopsy shows hyperplasia.
Tx: Medical management with scheduled progesterone for 2-3 months and re-eval with biopsy.
Case 3
You are called to the ER to evaluate a 49 year-old woman with a history of AUB. She says this is her
worst period yet. She is using both super pads and tampons at the same time and changing every 15-20
minutes. She has quarter to 1/2 dollar sized clots. She came to the ER because she started seeing black
spots and the room got fuzzy.
Vitals:
Weight: 150lbs
Height: 5'6"
BP: 80/50
P: 140
R: 18 ANSWER : -History:
Is this the first time the bleeding has been this heavy?
How long has the bleeding been this heavy? We want to establish if the heavy bleeding is acute or
chronic.
This patient started having changes in her cycle about a year ago. They went from monthly to every 2-3
weeks. Then about 5 months in, they got "heavier." Each progressive cycle required the use of more
products. The last 3 cycles have been very heavy and she uses "boxes" of pads and tampons. She has a
high deductible insurance and her sister and mother both had changes in periods like this that improved
when they got into menopause so she was hoping to do the same thing.
Any past medical history or family history of cancer?
, Remote history of gastric cancer in an uncle on her father's side.
Any past trauma/surgical history? Hysterectomy?
D+C for miscarriage at age 24.
Lap Chole at age 41.
No other surgeries.
What routine medications (if any) are you currently taking or have taken?
Takes a women's one a day multi vitamin and an OTC iron replacement twice a day.
Any history of coagulopathies?
NO
Any history of hypertension or cardiovascular disease?
Has not seen primary since her lap chole but had normal BP at the time. Last time the chol was checked
was at a Wal-mart pharm screening and it was just a little high.
Labs:
Beta-HcG blood test for pregnancy - NEGATIVE
CBC w/ platelets (Results):
RBC 4.0
HGB 5.0
HCT 26.0
MCV 62.0
MCH 20.1
MCHC 31.0
PLT 331
(ER'BODY) QUIZZES WITH RIGHT
ANSWERS.
Case 1
28 y.o. patient has change in menses consisting of cycles lasting 10 days. She is using 7-8 super pads per
day, and clots are nickel sized. Improves at night.
Vitals: Wt: 170
Ht: 5'8"
Pulse: 88
BP: 128/74
RR: 16 ANSWER : -My Initial Assessment:
-Her vitals are stable, i would still compare to a baseline if there is one for comparison for changes. Do a
pregnancy test. Is she anemic? Check her Hct.
-Her BMI is 25.8, she is overweight. I would ask her about any recent weight changes to see if that has
had an effect on her cycle?
-Menstrual bleeding assessment based on soaking 7 super pads per day with nickel sized clots = 414
points per day or 1410 points per week. She falls under the category of Menorrhagia/Heavy Menstrual
Bleeding. I would ask her about what changed about her period: Is it the same amount of bleeding but
for more days, or heavier bleeding for the same amount of days? Is this the only cycle that has been
different like this, or how many like these has she had now? If this is the first one, could she be pregnant
and she is having a miscarriage? Is she having lots of pain with menstruation?
-I would ask her if she is taking contraception? Birth Control, in all its forms usually makes periods lighter
and shorter. If she is starting a new birth control method, is it causing her to have menorrhagia.
-I would change her birth control based on the information that she provides if what she is newly on
isn't working for her.
-Could she have any of the PALM-COEIN causes of Menstrual bleeding.
-Physical Exam and palpation for fibroids or adnexal masses or tenderness and transvaginal U/S to see
fibroids or endometrial lining abnormalities.
-IF the bleeding continues: I would recommend endometrial biopsy to look for hyperplasia.
,-IF endometrial biopsy is normal, are her hormone levels normal? If her testosterone is high and her
periods are very heavy and irregular, then could she have PCOS?
-Continue to R/O causes on the PALM-COEIN list.
-Improvement with the bleeding at night: Im not sure what that could be except: except n
Case 2: A 56-year-old patient comes to the urgent care on Saturday. She is concerned because her
period started again this week. It was light and short but she had to use a full pad for 2 days and had
cramps. She had thought she was done with menopause 2 years ago.
This pt is using urgent care because she has no primary.
Vitals:
Weight: 230 Height: 5'7''
BP: 140/84 Pulse: 94 Respirations: 14 ANSWER : -Meds: Women's Silver OTC daily. She sometimes
remembers to take her calcium and vitamin D.
Family Hx: There is no family history of any "female cancers."
Social: No tobacco/EtOH use; has not been sexually active since her husband was killed in a work
accident 5 years ago.
Pelvic exam: reveals normal genitalia. She has a grade 1 cystocele that does not cause symptoms. When
asked she reports delivering 2 vaginal children, both 9 lbs. Vagina is somewhat dry with flattened rugae.
There is no blood in the vault. Cervix is parous and closed, non tender. Uterus is retroverted. It is difficult
to palpate true size due to patient's habitus however it does feel enlarged, possibly 12-14 weeks size.
She is non tender during exam. Adnexa are non palpable.
This patient has no insurance.
You discuss with her that you would greatly like to obtain a biopsy due to her length of time from
STRAW stage 0, her sudden menses, her enlarged uterus, and her risk factor for endometrial cancer
(age, obesity, and post menopausal status). This patient is able to have 1 test done at this time.
,Endometrial Biopsy shows hyperplasia.
Tx: Medical management with scheduled progesterone for 2-3 months and re-eval with biopsy.
Case 3
You are called to the ER to evaluate a 49 year-old woman with a history of AUB. She says this is her
worst period yet. She is using both super pads and tampons at the same time and changing every 15-20
minutes. She has quarter to 1/2 dollar sized clots. She came to the ER because she started seeing black
spots and the room got fuzzy.
Vitals:
Weight: 150lbs
Height: 5'6"
BP: 80/50
P: 140
R: 18 ANSWER : -History:
Is this the first time the bleeding has been this heavy?
How long has the bleeding been this heavy? We want to establish if the heavy bleeding is acute or
chronic.
This patient started having changes in her cycle about a year ago. They went from monthly to every 2-3
weeks. Then about 5 months in, they got "heavier." Each progressive cycle required the use of more
products. The last 3 cycles have been very heavy and she uses "boxes" of pads and tampons. She has a
high deductible insurance and her sister and mother both had changes in periods like this that improved
when they got into menopause so she was hoping to do the same thing.
Any past medical history or family history of cancer?
, Remote history of gastric cancer in an uncle on her father's side.
Any past trauma/surgical history? Hysterectomy?
D+C for miscarriage at age 24.
Lap Chole at age 41.
No other surgeries.
What routine medications (if any) are you currently taking or have taken?
Takes a women's one a day multi vitamin and an OTC iron replacement twice a day.
Any history of coagulopathies?
NO
Any history of hypertension or cardiovascular disease?
Has not seen primary since her lap chole but had normal BP at the time. Last time the chol was checked
was at a Wal-mart pharm screening and it was just a little high.
Labs:
Beta-HcG blood test for pregnancy - NEGATIVE
CBC w/ platelets (Results):
RBC 4.0
HGB 5.0
HCT 26.0
MCV 62.0
MCH 20.1
MCHC 31.0
PLT 331
