LAMPEN GYNE CONSULT

Dear Dr. Emily Carter, MAIN COMPLAINT: - Patient presents with complaints of heavy menstrual bleeding and pelvic pain. GYNECOLOGICAL: - Menarche at age 12, regular cycles until 6 months ago, now irregular and heavy. Reports using 6-8 pads per day during menstruation. No history of sexually transmitted infections. Last Pap smear was 1 year ago, normal. OBSTETRICAL: - G2P2 (Gravida 2, Para 2). Two vaginal deliveries. No complications during pregnancies or deliveries. FAMILY HISTORY: - Mother had a history of uterine fibroids. No other significant family history. MEDICAL HISTORY: - No significant medical history. MEDICATIONS: - Ibuprofen 400mg as needed for pain. PREVIOUS SURGERIES: - None. ALLERGIES: - NKDA (No Known Drug Allergies). SOCIAL HISTORY: - Non-smoker, occasional alcohol use. Works as a teacher. EXAMINATION: - General: Patient appears in mild distress due to pain. ABDOMINAL: - Soft, non-tender. No masses or organomegaly. GYNECOLOGICAL: - Speculum exam: Cervix appears normal. Uterus is enlarged and boggy. Bimanual exam reveals a palpable, mobile mass consistent with a fibroid. INVESTIGATIONS REVIEWED: - None at this time. INVESTIGATIONS ORDERED - CBC, pelvic ultrasound. IMPRESSION AND PLAN: - Impression: Heavy menstrual bleeding secondary to uterine fibroids. Plan: Discussed treatment options including medical management with hormonal therapy and surgical options such as myomectomy or hysterectomy. Scheduled for pelvic ultrasound and follow-up appointment in two weeks. DISCUSSION SURGICAL PROCEDURE: - Discussed the risks and benefits of myomectomy and hysterectomy. Patient expressed interest in preserving fertility, so myomectomy was discussed in detail. Informed consent obtained. Thank you for involving me in the care of the patient.