Background:
Patient is a 32-year-old female, presenting with a chief complaint of pelvic pain and irregular bleeding. Medical history includes a previous diagnosis of endometriosis, managed with hormonal therapy. Social history reveals the patient is a non-smoker and consumes alcohol socially. Family history is significant for a maternal history of ovarian cancer.
Problem list:
1. Pelvic pain: Onset approximately 2 weeks ago, described as a sharp, intermittent pain in the lower abdomen, rated 6/10 on the pain scale. Aggravated by physical activity and relieved by rest.
2. Irregular bleeding: Reported heavy bleeding for the past 7 days, with clots. Patient reports this is heavier than her usual period.
Investigations completed:
* Pregnancy test: Negative, performed today.
* Pelvic ultrasound: Scheduled for 08/11/2024.
Examination:
* General: Patient appears in mild distress due to pain.
* Vitals: BP 120/80 mmHg, HR 88 bpm, RR 16 breaths/min, Temp 37.1°C.
* Abdomen: Soft, with tenderness to palpation in the lower abdomen. No rebound tenderness or guarding.
Plan:
* Patient advised to rest and take over-the-counter pain relief (ibuprofen) as needed.
* Schedule pelvic ultrasound for further evaluation of the pelvic pain and bleeding.
* Review ultrasound results and discuss further management options, including potential referral to gynaecologist.
* Follow-up appointment scheduled for 2 weeks to review symptoms and investigation results.
Background:
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Problem list:
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Investigations completed mentioned in transcript, context or clinical note, else omit section entirely.)
Problem list:
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Investigations completed:
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Examination:
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Plan:
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