Thank you for your referral of Jane Doe, a pleasant 45-year-old woman referred for evaluation of abnormal uterine bleeding.
Reason for Consultation:
- Jane has been experiencing heavy menstrual bleeding for the past six months, with increasing frequency and volume.
History of Present Illness:
- The abnormal uterine bleeding began six months ago, characterized by prolonged and heavy periods lasting up to 10 days.
- Her menstrual cycles are typically 28 days, but the bleeding has become more severe over the last three months.
- She reports passing large clots and changing her tampon every hour during the heaviest days.
- She experiences intermenstrual spotting and postcoital bleeding.
- Associated symptoms include fatigue and mild pelvic pain.
- She previously tried oral contraceptives, which she discontinued due to side effects.
Past Medical History:
- Hypertension, diagnosed five years ago.
Medications:
- Lisinopril 10 mg daily.
Allergies:
- No known drug allergies.
Surgical History:
- Appendectomy at age 25, no complications.
Gynecological History:
- Last pap smear was two years ago, normal results.
- Menarche at age 13, no history of sexually transmitted infections.
Obstetrical History:
- G2P2, both pregnancies were full-term with no complications.
Social History:
- Non-smoker, occasional alcohol use, works as a teacher.
Family History:
- Mother had breast cancer at age 60.
Review of Systems:
- Positive for fatigue and pelvic pain, otherwise unremarkable.
Physical Examination:
- Vital signs: BP 130/85, HR 78, BMI 26.
- Pelvic exam: uterus slightly enlarged, no adnexal masses.
- Pap smear taken during the visit.
Investigations:
- Ordered CBC and pelvic ultrasound.
Assessment:
- Differential diagnosis includes fibroids and endometrial hyperplasia.
- Patient is at increased risk of endometrial cancer due to age and symptoms.
Plan:
- Scheduled for endometrial biopsy next week.
- Discussed potential treatment options, including hormonal therapy.
- Advised on lifestyle modifications to manage symptoms.
Once again, thank you for involving me in her care.
