Heavy periods with lost IUD strings case study guide

The vignette is compact but every clause is load-bearing: heavy menstrual periods and pelvic pain dating from placement of the ten-year IUD three years ago, a blood pressure of 152/94 and BMI of 46 recorded today, no palpable strings on your exam, a uterus that feels enlarged and boggy, and significant tenderness on bimanual. The differential list should grow straight out of those findings rather than from a textbook's index: a malpositioned, embedded, or perforating IUD leads because the missing strings demand it; the enlarged boggy uterus argues for adenomyosis and fibroids; pregnancy — intrauterine and ectopic — must sit on the list because no bleeding evaluation may proceed without excluding it; and infection, endometrial pathology given her obesity, and a displaced device causing both pain and bleeding round it out. Rank them and say which finding earns each its place.

The question the assignment is really built around is the branching one: how each IUD scenario changes management. Work it as two futures. If ultrasound locates the device in the uterus, the conversation becomes removal — which she has already requested — with the malposition explaining her symptoms and removal happening under ultrasound or hysteroscopic guidance if it is embedded. If ultrasound cannot find it, the algorithm continues rather than ends: an X-ray to distinguish an expelled device from one that has perforated into the abdomen, because a device on film but not in the uterus means surgical retrieval, while an absent device on film means expulsion and a contraception conversation. Writing both branches out in full, with the imaging step that separates them and the management each branch then requires, is precisely what the question is checking.

The remaining items reward using the whole patient rather than the presenting complaint. Further assessment should include the pregnancy test, hemoglobin for three years of heavy bleeding, infection screening given the tenderness, and endometrial evaluation reasoning that names her age and BMI; the counseling item wants her actual concerns answered — what removal involves, what can be done about the bleeding, and what contraception follows — in her terms; and today's plan should show what you can genuinely start now: the labs drawn, the imaging ordered, symptom management begun, and the interprofessional net cast. That last question is explicit, so name the collaborations — gynecology for the device and bleeding, primary care for the blood pressure of 152/94 and BMI of 46 that today's visit uncovered — and say what each contributes. A cleaning note: the record circulated with a student's answer ahead of the case; the brief above is the case and questions alone.