Patients : 24 Patient Gender : Female

1276 Words6 Pages
Melita Azarcon
S3477200
Patient age: 24 Patient gender: Female
Section 1
PRESENTING COMPLAINT:
• Aching lower back pain and abdominal cramping in the suprapubic region with 4-month history
• Pain comes on usually a day before her period starts
• Pain is at its worst during the first 2 days of menstruation
• She finds it difficult to continue on with daily activities and will often have to call in sick at work or cancel plans and spend the day in bed (she has called in sick 4 times over the past 3 months because of this pain)
• Relatively painless menstrual periods in the past
• She had been on the pill for 4 years but stopped in June 2015
• When on the pill, her periods were very light and would only last 3-4 days. She did not experience any back pain, cramping or fatigue
• Pain has since escalated to severe lower back pain with abdominal cramping
• She has noticed that her periods have been heavier this year compared to when she was in her teens and when she was on the pill
• Regular 25-28 day cycles
• She uses heat packs to relieve the pain and will take NSAIDs if the pain worsens
PAST TRAUMA
NAD
SERIOUS ILLNESSES
NAD
SURGERY
NAD
INVESTIGATIONS (Laboratory, X-Rays, MRI’s etc)
She hasn’t seen her GP about this pain, no investigations have been performed
MEDICATIONS
She is not currently on any medication/supplements/vitamins. She was using Microgynon 30 ED (combined oral contraceptive pill) from April 2011 to June 2015

FAMILY HISTORY
Her father was recently

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