The document details a comprehensive evaluation of a 41-year-old Hispanic American female presenting with abnormal uterine bleeding and severe cramping, diagnosed primarily with adenomyosis. It outlines her medical history, symptoms, physical examination findings, and diagnostic tests revealing significant uterine abnormalities. A treatment plan involving total hysterectomy was agreed upon due to the patient's preference and the severity of her symptoms.

1. 1
[Shortened Title up to 50 Characters] 16Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI,
2012) described abnormal uterine bleeding as bleeding that
differs in quality and quantity from normal menstrual bleeding,
such as women spotting or bleeding between the women’s
menstrual periods; bleeding after sex; bleeding heavier or last
more days than normal; and bleeding post menopause.
According to SREI (2012), factors that can cause abnormal
bleeding include structural abnormalities of the reproductive
system, such as uterine polyps, fibroids, and adenomyosis.
Furthermore, SREI (2012) explained that vaginal, uterine or
cervical lesions, miscarriage, ectopic pregnancy, endometritis,
adhesions in the endometrium, and use of an intrauterine device
(IUD) can also cause abnormal bleeding. Johns Hopkins

2. Medicine (2016) specified that early recognition of abnormal
bleeding, and seeing a health care provider immediately for
appropriate diagnosis and treatment increase the chance of
successful treatment. Therefore, the author will focus on a
single patient comprehensive evaluation, which includes the
patient’s personal/health history; physical examination;
laboratory/diagnostic tests; diagnosis; treatment/management
plan; education strategies; and follow-up care. Comment by
DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender:
This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding
with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic
American female who presented to the clinic with complaint of
heavy prolonged menstrual bleeding with severe cramping for
the past one year. Patient reported sharp pelvic pain during
menstruation, bleeding between periods, pain with intercourse,
blood clots during periods. Abdominal pain/pressure and
bloating. Patient suggested that these symptoms started after her
second caesarean section surgery one year ago. Patient also
reported that she takes over-the counter medication, such as
ibuprofen to relieve the pain. she also suggested that she uses
heating pad on her abdomen/pelvic for pain relief, and she
stated that she soaks in a warm sitz bath to ease pelvic pain and
cramping. Patient also reported fatigue and weakness. Patient
further stated that she decided to see an obstetrician and
gynecologist (OB/GYN) because the heavy prolonged bleeding
with severe menstrual cramp interfere with her regular
activities. Patient denied nausea, vomiting, diarrhea, fever, and
chills.

3. Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is
pelvic/uterus/vaginal.
Duration: 5 to7 days during periods for the past one year.
Quality/Characteristic: Patient reported heavy prolonged
menstrual pain; severe, sharp lower abdominal/pelvic
cramping/pain, and blood clots during periods.
Aggravating Factors: Monthly periods as stated by the patient.
Relieving/Alleviating Factors: Patient stated that ibuprofen pain
medication, heating pad, and/or warm sitz bath help the
pain/cramping.
Severity: The severity of the pain/cramping on a pain scale is
10/10 reported by the patient.
Treatments/Therapies: Patient stated that she had not undergone
any treatment for the reported problems.
Last Menstrual Period: The last menstrual period reported by
patient was 7/5/2016.
Sexual Activity Status: Patient reported being sexually active.
Barrier Prevention: Patient stated she uses natural barrier
methods.
Sexual Preference: Patient sexual preference is
monogamous/heterogeneous relationship.
Satisfaction with Sexual Activity: Patient reported that she is
sexually satisfied with her partner.
Contraception Method: Patient denied using any contraception
method.
Patient History
Past medical History (PMH): Anemia and C-section. Patient was
delivered full term through vaginal delivery without
complications. The birth weight was 8 pounds 10 oz.
Psychological/Mental Health: Patient denied depression, mood
swings, anxiety, or mental health problem.
Medications: RG reported that she takes over the counter Motrin
200-400 mg orally every 4-6 hours as needed for pain and
cramping.

4. Allergies: Patient reported no known allergies (NKA).
Past Surgical/Hospitalization History: Patient reported history
of C-section twice, and she was hospitalized for 3 days post the
C-sections.
Preventive Screening: Patient reported that she had flu shot on
11/20/2015; last mammogram was 2/12/2015 and mammogram
was normal; Pap smear was on 2/20/2015, which was also
normal; patient also reported that she was up to date with her
childhood immunization, but denied pneumococcal vaccination.
Family History: Both father and mother have history of diabetes
mellitus type 2 and hypertension. Both parents are still living,
and two siblings are still living and well.
Gynecological History: Patient is multipara with 2 pregnancy
resulting in two viable offsprings. Patient had her first child at
the age of 33 years. Menarche at age 13; periods last between 5
to 7 days. Patient reported heavy prolonged menstrual bleeding
with severe cramping; sharp pelvic pain during menstruation;
and bleeding between periods for the past one year. Denied
vaginal discharge or sexually transmitted infection/disease.
Obstetric History: Gravida 2, Para 2, term 2, preterm 0,
spontaneous abortion 0, and living 2 (G2T2P2A0L2). Gravida 1:
Delivered at 39 weeks by C-section on 4/20/08 male; Gravida 2:
Delivered at 40 weeks by C-section on 2/18/15 female. Patient
denied therapeutic abortion (TAB) or spontaneous abortion
(SAB); Patient denied preterm or low birth weight baby with no
delivery complications. Patient also denied having sexual
transmitted disease.
Personal/Social History: Patient is married with 2 children, and
lives at home with the husband. Patient is a college graduate;
works outside the house as a nurse at a nearby hospital.
Patient’s husband works for a computer company. Patient
family is a middle income family. Also, patient denied any
physical or psychological abuse. Patient denied being exposed
to any environmental or occupational health hazards. Patient

5. also denied alcohol consumption, tobacco, or recreational drug
use. Patient denied participating in any exercise or physical
activity because she is tired after work, and prefers to rest.
Patient reported that she eats healthy; she eats low fat, low
carbohydrate meals, and she eats fruits and vegetable at least 3
to 4 times a week. Patient stated
that she sleeps well at night, and she usually goes to bed at 9
pm and wakes up at 6 am. Patient drinks a cup of coffee
occasional, especially when she is at work to be awake.
Review of System (ROS)
General: RG admitted fatigue and weakness; denied fever
/chills; and no weight loss.
Head and Neck: Patient denied headache or dizziness. Patient
also denied lumps, neck injury, pain/tenderness or jugular vein
distention.
Chest: Patient denied chest pain, cough or shortness of breath.
Heart: RG denied irregular heartbeats, heart attack, or heart
murmur.
Breasts: Patient denied nipple discharge, tenderness or swelling.
Gastrointestinal: Patient admitted lower abdominal pain,
pressure, and bloating; denied constipation, nausea, vomiting,
and diarrhea.
Genitourinary: RG denied urinary tract infection, urinary
frequency or burning on urination.
Genital: Patient admitted heavy prolonged menstrual bleeding
with severe cramping for one year. Patient admitted sharp
pelvic pain during menstruation, bleeding between periods, pain
with intercourse, and blood clots during periods. Patient denied
vaginal discharge.
Musculoskeletal: RG denied varicosities or extremities problem.
Psychiatric: RGdenied depression, anxiety, or any psychiatric
problems.
Neurological: Patient admitted fatigue and weakness; denied
confusion, seizures, or tingling.
Hematologic: Patient admitted history of anemia; denied blood

6. transfusion or easily bruise or bleeding.
Physical Examination
General exam: Patient appeared well developed and pleasant
with good hygiene. Patient also appeared pale and weak. Vital
signs: Blood pressure 118/76, heart rate 80, respiration 18,
temperature 98.8, pulse ox 100% on room air. Weight 78.2 kg,
height 67 inches, and body mass index (BMI) 27.
HEENT: The head is normaceplalic, atraumatic. The pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Tympanic membrane is gray
bilaterally. Oral mucosa is dry. Oropharynx is clear. Nares are
patient, no nasal or septal deviation noted. No pharyngeal
erythema.
Neck: Noted to be supple without jugular vein distention (JVD),
thyromegaly or lymphadenopathy.
Lungs: Noted to be clear to auscultation throughout the lobes;
no wheezes or rhonchi noted.
Cardiovascular: Regular rate and rhythm on auscultation, S1 S2
present without murmurs. Palpable pulses noted without
peripheral edema.
Gastrointestinal: Bowel sounds are active in all quadrant.
Abdomen is soft and tender on palpation.
Breast: The size of the breasts, areolas, and nipples are round
and symmetrical with no discoloration, rash, lesions, dimpling,
or retraction bilaterally; no masses, lumps, or tenderness noted
on palpation bilaterally; and axillary lymph nodes non-palpable.
Pelvic Examination:
Vulva: The hair distribution is normal; no lesion noted.
Vagina: Vaginal walls are pink, and pubic hair is shaven; no
lesions, masses, inflammation or discharge noted.
Cervix: Intact cervix with closed os.
Uterus: Enlarged, asymmetrical, soft, boggy and tender.

7. Laboratory and Diagnostic Tests
Laboratory Test and Results: Pregnancy test: Result is negative.
Hemoglobin and Hematocrit (H/H): Result showed H/H
8.7/26.7, which is positive for anemia.
Diagnostic:
Transvaginal ultrasonography of the uterus: Revealed uterine
enlargement measuring 12 cm with no leiomyomata; uterine
wall thickening; cystic anechoic spaces in the myometrium;
heterogeneous echo texture; obscured endometrial/myometrial
border; sub endometrial echogenic linear striations; and
thickening of the transition zone measuring 12.8 millimeter.
The transvaginal sonography is used to rule out possible uterine
tumor (Sakhel & Abuhamad, 2012).
Magnetic Resonance Imaging (MRI): MRI is ordered to obtain a
high resolution image of the uterus as well as
verifying/confirming the suspected diagnosis. The MRI result
revealed that the junctional zone of the uterus is thickened and
measures 12.8 millimeter. Also, MRI revealed an ill-defined
ovoid and diffuse region of thickening with striated appearance
(Sakhel & Abuhamad, 2012).
Differential Diagnoses
The differential diagnoses of the patient clinical presentation as
described by Schuiling and Likis (2013) include: Adenomyosis,
uterine fibroids and endometrial hyperplasia. However, the
primary diagnosis for the patient is Adenomyosis.
Adenomyosis: Schuiling and Likis (2013) described
adenomyosis as a benign, common condition that involves the
movement of endometrial tissue into the uterine muscles. The
definitive cause of the adenomyosis is unknown, but the
condition is common among women with elevated levels of
estrogen; the condition usually ceases post menopause when
estrogen levels are reduced. Risk factors explained by Taran,
Stewart, and Brucker (2013) include multiparity; previous
uterine surgery, such as C-section, dilatation/curettage, or
fibroids
removal surgery; and women at reproductive age, especially

8. between the age of 40s or 50s. furthermore, Taran et al. (2013)
specified that the clinical presentation entails chronic pelvic
pain, prolonged menstrual cramps, heavy menstrual bleeding,
spotting between periods, abdominal tenderness, painful
intercourse, longer periods than normal, blood clots during
periods. Taran et al. (2013) also explained that finding during
physical examination include enlarged, tender, soft and boggy
uterus. According to Taran et al. (2013) diagnosis is made based
on sonographic or MRI results, and treatment is not
recommended for women with mild form of adenomyosis,
except when the symptoms interfere with daily activities. Taran
et al. (2013) further explained that treatment options include
anti-inflammatory medications; hormonal treatments;
endometrial ablation; uterine artery embolization, MRI-guided
focused ultrasound surged or hysterectomy, which is the
definitive treatment for adenomyosis.
Adenomyosis is selected as the primary diagnosis because
the aforementioned patient’s clinical presentation, physical
examination findings, and diagnostic tests results are
synonymous with adenomyosis aforementioned associated signs
and symptoms; risk factors; physical examination findings; and
diagnostic test results.
Uterine Fibroids: Women’s Health (WH, 2015) described
uterine fibroid to be muscular tumors that develop in the uterine
wall, which can also be referred to as leiomyoma or myoma.
Uterine fibroids are usually non-cancerous, and can be single or
multiple tumors in the uterus. According to WH (2015), women
risk for developing uterine fibroid are increased by age, such as
women in their 30s and 40s until menopause when the fibroids
commonly shrink. Other risk factors include family history,
ethnic origin, obesity and eating habits. Symptoms of fibroids
as explained by WH (2015) involve lower back pain; pain
during sex; heavy bleeding; painful menses, enlarged lower
abdominal, frequent urination; and lower abdominal/pelvic
feeling of fullness. Physical examination shows reveal painless,
firm, irregular pelvic mass. According to WH (2015),

9. diagnosis is done using transvaginal ultrasound, MRI,
hysteroslpingography, hysteroscopy, and endometrial biopsy.
Fibroid is not selected as the primary diagnosis because there is
no visualization of the fibroid during pelvic examination or on
sonography test. Moreover, severe pain is noted during pelvic
exam. Furthermore, sonographic result is more consistent with
adenomyosis rather than fibroids.
Endometrial Hyperplasia: Cancer Research of United Kingdom
(CRUK, 2014) described endometrial hyperplasia as thickening
of the covering of the uterus due to excessive growth of the
cells that covers the uterus, and endometrial hyperplasia can
lead to womb cancer. Risk factors according to CRUK (2014)
include- age over 35 years; white race; nulliparity; older age at
menopause; obesity; cigarette smoking; family history of
ovarian, colon, or uterine cancer; early menarche; and history of
diabetes, polycystic ovary syndrome, thyroid disease and
gallbladder disease. The CRUK (2014), explained that the
condition is caused by imbalance of to the estrogen and
progesterone. According to CRUK (2014), signs and symptoms
of endometrial hyperplasia includes abnormal, prolonged, heavy
periods; bleeding between periods; shorter than 21 days’
menstrual cycles; and bleeding after menopause. Also, diagnosis
is established by vaginal ultrasound scan, dilatation and
curettage, or hysteroscopy.
23rd ed. Philadelphia, PA: Lippincott Williams &.Wilkins;
2014presentation, physical findings during examination; and
diagnostic results are not synonymous with the signs and
symptoms; physical examination finding, risk factors and
diagnostic
results associated with endometrial hyperplasia (American
College of Obstetricians and Gynecologist, 2016).
Management Plan
Diagnosis: The only definitivediagnosis of adenomyosis is
established after uterus is examined post hysterectomy.
However, clinical findings that helped in the diagnosis of the
patient includes enlarged, asymmetrical, soft, boggy and tender

10. uterus during pelvic examination and aforementioned
sonographic and MRI findings, which synonymous with the
diagnosis of adenomyosis (Sakhel & Abuhamad, 2012).
Treatment: Treatment was considered based on the patient
clinical presentations, and collaborative agreement with the
patient, the author, and the preceptor for total hysterectomy
after explanation of the treatment options to the patient. Patient
selected hysterectomy because patient does not want to have
another child. According to Schuiling and Likis (2013)
explanations, patient was advised to continue with the over-the
counter anti-inflammatory drug: Motrin 200-400 mg orally
every 4-6 hours as needed for pain and cramping until
hysterectomy is performed. Also, Ferrous sulfate 325 mg orally
three times a day for anemia was prescribed. Patient was
educated to take the medication on an empty stomach one hour
before meal or 2 hours after meal for optimum absorption.
Patient Education: Patient was educated on the risk factors for
adenomyosis, the causes, symptoms, diagnosis, and treatment
options. Patient was educated that most women with
adenomyosis does not have any symptoms, but adenomyosis is
usually found after the tissue obtained from the uterus has been
biopsied after pelvic surgery. Patient was also informed that the
C-section she had twice during child birth may have put her at
risk for adenomyosis. Patient was informed that the symptoms
of adenomyosis goes away after menopause or after
hysterectomy. Patient was educated that all options of treatment
must be tried before hysterectomy, but patient opted for
hysterectomy without trying all options of treatment.
furthermore, patient was educated to continue the home remedy,
such as continuation of the use of the heating pad, warm soak
bath, and continuing with the over the counter Motrin to
alleviate the pain associate with the condition. Finally, patient
was educated on the psychological and emotional effects of
adenomyosis and hysterectomy surgery because some women
grieve on the loss of their womb, which may put them into
depression as a result of that; the patient has to be completely

11. sure that she really wants to do the surgery at her age now or
wait and do the surgery in the future (University of Maryland
Medical Center, 2016).
Follow Up Care: In consideration of the Schuiling and Likis
(2013) discussion, patient was schedule to follow-up in 6 weeks
for follow-up on the patient’s anemia and surgical work up labs,
such as complete blood count, complete metabolic panel,
prothrombin time and international normalized ratio(PT/INR).
Also, an electrocardiogram (EKG) and chest x-ray was ordered
to rule out any cardiac problem that would complicate the
hysterectomy surgery. The patient’s H/H came up to 11.5/38.9
and all the other laboratory and diagnostic result was normal.
The Total hysterectomy surgery was performed on 7/27/2016.
Surgery was successful, and patient was schedule to follow up
in six eek post-surgery.
Conclusion Comment by DeAllen B Millender:
Level 1 headings are centered, in bold print, and in 'Title Case'
(Chapter 3, 3.03, pp. 62-63; see Table 3.1 and Figure 2.1).
The author selected a patient at the author’s clinical site, and
obtained a complete health history following the patient care
from the beginning of the clinical up to 9 weeks of clinical. The
author also used the patient health information and clinical
presentation to come up with a diagnosis of adenomyosis. The
author developed an appropriate treatment plan with the patient
in collaboration with the author’s preceptor incorporating the
author’s classroom knowledge with the author’s chosen nursing
theorist. Finally, the patient was educated on the condition and
follow up care.

12. References
American College of Obstetricians and Gynecologist. (2016).
Endometrial Comment by DeAllen B Millender:
Paper and poster titles presented at meetings that are not a part
of a symposium should be in italics (Chapter 7, 7.04, p. 206).
Hyperplasia. Retrieved from http://www.acog.org/Patients/
FAQs/Endometrial-Hyperplasia
Cancer Research of United Kingdom. (2014). Endometrial
hyperplasia. Retrieved from
http://www.cancerresearchuk.org/about-cancer/cancers-in-
general/cancer-questions/endometrial-hyperplasia
John Hopkins Medicine. (2016). Recognizing gynecologic
problems. Retrieved from
http://www.hopkinsmedicine.org/healthlibrary/
conditions/adult/gynecological_health/recognizing_gyneco
logic_ problems_85,P00584/
Sakhel, k., & Abuhamad, A. (2012). Sonography of
adenomyosis. Journal of Ultrasound in Medicine, 31(12), 805-
808.
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic
health (2rd ed.). Burlington, MA: Jones and Bartlett Publishers.
Society for Reporoductive Endocrinology and Infertility.
(2012). Abnormal uterine bleeding. Retrieved from

13. http://www.socrei.org/BOOKLET_abnormal_uteine_bleeding/
Taran, F. A., Stewart, E. A., & Brucker, S. (2013).
Adenomyosis: Epidemiology, risk factors, clinical phenotype
and surgical and interventional alternative to hysterectomy.
Geburtshilfe Frauenheilkunde, 73(9), 924-931.
University of Maryland Medical Center. (2016). Adenomyosis.
Retrieved from
http://umm.edu/health/medical/ency/articles/adenomyosis
Women’s Health. (2015). Uterine fibroids fact sheet. Retrieved
from
http://www.womenshealth.gov/publications/our-
publications/fact-sheet/uterine-fibroids.html#c
1. Comprehensive Write-up Guide Assignment: Comprehensive
Patient Assessment
2. When completing practicum requirements in clinical settings,
you and your Preceptor might complete several patient
assessments in the course of a day or even just a few hours.
This schedule does not always allow for a thorough discussion
or reflection on every patient you have seen. As a future
advanced practice nurse, it is important that you take the time to
reflect on a comprehensive patient assessment that includes
everything from patient medical history to evaluations and
follow-up care. For this Assignment, you begin to plan and
write a comprehensive assessment paper that focuses on one
female patient from your current practicum setting.
To complete:
Write an 8- to 10-page comprehensive paper that addresses the
following:
1. General patient information a. Age b. Race/ethnicity c.
Partner status
2. Current health status a. Chief concern/complaint and history

14. of present illness (include a complete symptom analysis of chief
complaint(s) utilizing OLDCART for a sick/problem focused
visit) b. Last menstrual period or year of menopause c. DES
exposure (if born between 1948 and 1971) d. Sexual activity
status e. Barrier prevention f. Sexual preference g. Satisfaction
with sexual relations
3. Contraception method (if any)
4. Patient history a. Past medical history • Major medical events
(including pediatric events) • Psychological and mental health
• Surgeries and/or hospitalizations if pertinent • Medications,
including prescriptions, over-the-counter medications, home and
herbal remedies, calcium, and vitamin supplements • Allergies,
including drug, food, and environment
3. © 2013 Laureate Education, Inc. 2
· Health maintenance/screenings, including results of patient’s
last Pap and mammogram as appropriate, as well as previous
vaccinations (HPV, MMR, hepatitis B, last dT, and
pneumovax/influenza as appropriate)
4. b. Family medical history
5. c. Gynecologic history • Nullipara vs. multipara • History of
sexually transmitted infections and sexually transmitted
diseases • Menarche and menstrual patterns • Menopause or
peri-menopausal symptoms (if applicable)
6. d. Obstetric history • Gravida and parity status (TPAL) •
Pregnancy history, including history of preterm or low birth
weight, other pregnancy complications, history of sexually
transmitted diseases, and any pertinent negatives
7. e. Personal social history (as appropriate to the current
problem) • Cultural background • Education and economic
condition • Abuse history including assault and forced sex (past
and current) • Occupational health patterns • Environment •
Current health habits and/or risk factors • Substance use (must
include for every patient) • Tobacco including frequency and
longevity • Alcohol including results of CAGE unless patient

15. has never used • Recreational drug use (past and current) •
Exercise and physical activity • Diet and nutrition • Sleep •
Caffeine
5. Review of systems (ROS) a. Must include reproductive
system as well as other pertinent systems (systems relevant to
HPI should be included under HPI)
6. Physical exam a. General exam, including vital signs, height,
weight, and BMI on every patient b. Physical exam focused on
episodic complaint (include numbers of weeks gestation, fundal
height, and fetal heart tones for OB patients)
7. Labs, tests, and other diagnostics
8. © 2013 Laureate Education, Inc. 3
a. Pertinent labs, test, and other diagnostics (include routine
tests such as triple screen and urine dip for OB patients)
8. Differential diagnoses a. Explain why this set of differential
diagnoses should be considered and why each diagnosis should
be ruled in or ruled out.
9. Management plan a. Diagnosis b. Treatment c. Patient
education d. Follow-up care
Reminder: The School of Nursing requires that all papers
submitted include a title page, introduction, summary, and
references.
SAMPLE PAPER( DO NOTE COPY)