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Case 5.3 Menstrual Cramps

By Vera Borkowski, MSN, APRN, FNP‐C

SUBJECTIVE

Khaleesi is a 16‐year‐old who comes to the school‐based health center (SBHC) after she just got her period in school. She is requesting a pad or tampon from SBHC because “I’m embarrassed … I soaked through my clothes.” Khaleesi says she usually misses “about 1 or 2 days each month because of my period.” While checking the patient into the electronic health system, it is noted her school absences are high. She reports she’s gotten her period since age 11, every month, but once she got it twice in one month. She uses 6 pads or tampons on the heaviest days, but her period usually only lasts about 5 days. She says her cramps, “aren’t too bad usually, but sometimes I will throw up when they are really bad.” She reports “I think my mom gives me Advil sometimes?,” but she does not use medication every period, and “it only helps sometimes.” Khaleesi denies any urinary frequency, urgency, dysuria, hematuria, vaginal discharge, pruritus, lesions, or lower abdominal pain other than “my normal cramps.”

Past medical history: Tonsillectomy and adenoidectomy around age 8; seasonal allergies.

Family history: Khaleesi’s mother and aunts with heavy periods.

Social history: Denies drug, alcohol, or vaping use. Denies any sexual activity (oral, anal, or vaginal) current or in past.

Medications: Zyrtec 10 mg only in springtime for allergies.

Allergies: NKDA, no food allergies.

OBJECTIVE

Vital signs: Height: 61 in; weight: 122 lbs; BP: 118/68; HR: 80; RR: 12; BMI: 23. Pain 5/10 on numeric scale, lower abdominal. Patient Health Questionnaire‐2 = 0 negative screening.

General: Pleasant, well developed, well nourished, in no acute distress.

Respiratory: CTA bilaterally, no wheezes, rales, or rhonchi.

Cardiac: RRR, S1 S2 normal with no murmurs, rubs, or gallops.

Breast: Tanner V symmetrical.

Abdomen: Bowel sounds present, abdomen soft, nontender, nondistended with no hepatosplenomegaly.

Genitourinary: Pubic hair; Tanner V normal female; + menses.

CRITICAL THINKING

1 What is the most likely differential diagnosis and why?___Dysmenorrhea___Endometriosis___Pelvic inflammatory disease (PID)___Urinary tract infection (UTI)___Appendicitis___Pregnancy—threatened abortion___Pregnancy—ectopic

2 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Pelvic and transvaginal ultrasound___CBC with differential___CMP___Urine pregnancy test___Pelvic exam with cervical swab for GC/CT

3 What questions would you ask Khaleesi about her menstrual cycle?

4 What additional information/questions are needed?

5 What is the plan of treatment?

6 Are there other options?

7 Is it common for teen girls to miss school because of their periods?

8 When should she be seen for follow‐up?

9 What health education should be provided to this patient?

10 Are there technologies available to assist this patient in her care?