• Explain how missing information from the patient history might change the diagnoses for the patients in the posting selected.

• Based on your personal and/or professional experiences, expand on your postings by providing additional insights or contrasting perspectives.

Case Study 1:
A 32-year-old African American female is concerned about increasing dysmenorrhea over the past three years. In the past year, this was associated with painful intercourse. She has been in a monogamous relationship with one male partner for the past five years. They tried to have children without success. Menarche was at age 10; menstrual cycles are 21 days apart and last for 6–7 days. The first day of her last menstrual period was 10 days ago and was normal. She denies vaginal itching or discharge. On gynecologic exam there was no swelling, external lesions, or erythema, urethral swelling, or vaginal discharge. Cervix is pink without lesions or discharge. Uterus was small, retroverted, and non-tender. Adnexa were small and non-tender. Nodules are noted along the cul de sac.

DDX: Endometriosis (pelvic inflammatory disease (PID), primary dysmenorrhea)

Endometriosis
There are many different clinical signs of endometriosis, making the diagnosis difficult and requiring tissue biopsy and histology for confirmation (Schenken, 2019). Signs and symptoms of dysmenorrhea, dyspareunia, infertility, and chronic pain. Anterior and posterior cul-de-sac nodules is a common anatomical site finding for endometriosis (Schenken, 2019). In this case study, the patient has nodules on the cul de sac and is expressing concerns of dysmenorrhea that has progressed in the last year to include dyspareunia. This is my primary diagnosis. Diagnosis is made with transvaginal ultrasound or MRI findings of ovarian cysts, nodules on rectovaginal septum and bladder nodules (Schenken, 2019). Biopsy of the nodules will then confirm diagnosis of endometriosis.

Differential diagnosis include PID and primary dysmenorrhea. PID may involve the uterus, fallopian tubes, and/or ovaries. Greater than 80% of the time PID is caused from a sexually transmitted disease. Cardinal sign is lower abdominal pain and can worsen during coitus and nearing the time of menses is also common (Ross & Chacko, 2018). Other findings of PID include abnormal vaginal discharge, changes to urinary frequency, acute cervical motion, uterine, and adnexal tenderness on exam (Ross & Chacko, 2018). In this case, it was noted absence of adnexal and uterine tenderness and cervical discharge. PID can lead to endometriosis amongst other diseases.

Primary dysmenorrhea commonly starts in adolescents and continues through maturation. The patient may have no physical findings; the pain typically occurs during all menstrual cycles. The pain can range from mild to severe and is associated with headache, nausea, diarrhea, and general malaise (Smith & Kaunitz, 2019). Menses prior to age 12 is often associated with primary dysmenorrhea. The patient does have other findings, making this my least likely diagnosis.