Date: 1 November 2024
34y/o female, now with heavy and painful menstrual periods.
Medical History:
34y/o female
# Hypertension, well-controlled on Amlodipine 5mg OD, no target-organ-damage. Latest BP 128/76 mmHg. No recent blood tests available.
# Past appendectomy in 2005, uncomplicated.
# Allergies: Penicillin - anaphylaxis
Gynaecological History:
Menarche: 12 years old
Cycle length: Irregular, 21-28 days
Severity of bleeding: Heavy, requiring change of super plus tampon every 1-2 hours for 3 days; clots present. Associated with severe dysmenorrhoea.
Sexually active: Yes, in a monogamous relationship, uses condoms for contraception.
Gravida: 2
Parity: 2
Dyspareunia: Occasional, mild, deep dyspareunia.
Personal history of malignancy: None
Familial history of malignancy: Maternal aunt had ovarian cancer at age 55.
Weight issues: No significant weight fluctuations, BMI 24.
History of sexual trauma: Denied
Presenting Complaint:
Patient presents with a 6-month history of increasingly heavy and painful menstrual periods (menorrhagia and severe dysmenorrhoea). Bleeding lasts 7-8 days, with 3 days of very heavy flow. Pain is described as cramping, radiating to the back and thighs, 8/10 severity during heavy flow, partially relieved by ibuprofen. Associated with fatigue and occasional dizziness. Denies intermenstrual bleeding, post-coital bleeding, or abnormal vaginal discharge. Denies recent changes in contraception or lifestyle.
Social History:
Works as a primary school teacher. Lives with her partner. Does not smoke. Occasional alcohol consumption (1-2 units per week). Exercises regularly. Reports increased stress due to work.
Physical Examination:
BP: 125/78 mmHg
HR: 72 bpm
SATS: 98% on room air
T: Apyrexic
HGT: 5.2 mmol/L
Hb: 11.5 g/dL (from recent FBC)
Weight: 68 kg
Height: 168 cm
General appearance:
Appears comfortable, alert and oriented. No pallor noted.
Respiratory system:
Normal chest expansion, clear breath sounds bilaterally, no adventitious sounds.
Cardiovascular system:
S1 S2 heard, no murmurs, rubs, or gallops. Normal peripheral pulses, no oedema.
Neurological system:
GCS 15, pupils equal and reactive, oriented to time, place, and person. Cranial nerves intact. Motor and sensory findings normal.
Other relevant systems:
Thyroid: No palpable goitre or nodules.
Gynaecological Examination:
Breast examination:
No masses, tenderness, or nipple discharge. Symmetrical.
Abdominal system:
Soft, non-tender, non-distended. No palpable masses or organomegaly. Bowel sounds present.
External genitalia:
Normal female external genitalia, no lesions, discharge, or signs of inflammation.
Internal genitalia:
Speculum examination: Cervix appears healthy, no lesions or discharge. Vault clear. Bimanual examination: Uterus anteverted, normal size, smooth, mobile, mildly tender to palpation. Adnexa non-tender, no masses appreciated.
Assessment:
34-year-old female presenting with menorrhagia and severe dysmenorrhoea, concerning for endometriosis or adenomyosis given the painful heavy periods and deep dyspareunia. Anaemia secondary to blood loss is possible, though current Hb is borderline. Fibroids remain in the differential.
Plan:
1. Biochemistry requested: Full Blood Count (FBC), Ferritin, Thyroid Function Tests (TFTs), Coagulation screen.
2. Imaging: Pelvic ultrasound to assess for fibroids, adenomyosis, or ovarian pathology.
3. STAT medication: Not required.
4. Pharmacology: Discussed trial of Tranexamic Acid for heavy bleeding and Mefenamic Acid for pain during periods. Discussed potential for hormonal contraception (e.g., combined oral contraceptive pill or Mirena IUS) for long-term management.
5. Gynaecologist opinion or referral: Referral to Gynaecologist for further evaluation and management, especially if conservative measures are ineffective or imaging is abnormal.
6. Allied health referral: Not required at this stage.
7. Counselled on: Nature of her symptoms, potential causes (endometriosis, adenomyosis, fibroids), management options (symptomatic relief, hormonal), and importance of further investigation.
8. Follow-up instructions: Return for review of blood test and ultrasound results in 2-3 weeks. Monitor symptoms and effectiveness of new medications.
Tasks to be created:
Referral letter to Gynaecology. Request forms for FBC, Ferritin, TFTs, Coagulation screen, and Pelvic Ultrasound.
Date: [Insert date of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Insert patient age in years]y/o [Insert male or female], now with [Insert most important acute or primary issue]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write the entire statement in full sentences.)
Medical History:
[Insert patient age in years]y/o [Insert male or female] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
# [Insert one medical comorbidity per line, including control status and medications used, and include past surgeries with indications or complications if mentioned. Include target-organ-damage for cardiovascular conditions and relevant blood results if mentioned.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
# Allergies: [Insert specific allergy and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Gynaecological History:
Menarche: [Insert menarche details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cycle length: [Insert cycle length] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Severity of bleeding: [Insert severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Sexually active: [Insert yes/no/details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Gravida: [Insert gravida] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Parity: [Insert parity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Dyspareunia: [Insert details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Personal history of malignancy: [Insert details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Familial history of malignancy: [Insert details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Weight issues: [Insert details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of sexual trauma: [Insert details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Presenting Complaint:
[Insert presenting complaint described in clinical terms, including issue, duration, associated issues, important negatives, and alleviating or exacerbating factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
[Insert relevant social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
BP: [Insert blood pressure reading in mmHg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HR: [Insert heart rate in bpm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SATS: [Insert oxygen saturation and oxygen status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
T: [Insert temperature or state apyrexic] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HGT: [Insert glucose in mmol/L] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hb: [Insert haemoglobin in g/dL] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Weight: [Insert weight in kg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Height: [Insert height in cm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
General appearance:
[Insert general appearance findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Respiratory system:
[Insert respiratory examination findings including air entry and adventitious sounds] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cardiovascular system:
[Insert cardiovascular examination findings including heart sounds, failure status, and pulses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological system:
[Insert neurological findings including GCS, pupils, orientation, cranial nerves, and motor/sensory findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other relevant systems:
[Insert findings for other systems examined, specifying system and details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Gynaecological Examination:
Breast examination:
[Insert breast examination findings or normal examination statement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Abdominal system:
[Insert abdominal examination findings or normal examination statement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
External genitalia:
[Insert external genitalia findings or normal examination statement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Internal genitalia:
[Insert internal genitalia findings or reason for deferral if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
[Insert clinical assessment including working diagnosis, differentials, supporting findings, and complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
1. Biochemistry requested: [Insert blood work requested] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. Imaging: [Insert imaging ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. STAT medication: [Insert urgent medication with name, dose, route, and time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
4. Pharmacology: [Insert new medications or medication changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
5. Gynaecologist opinion or referral: [Insert opinion or referral details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
6. Allied health referral: [Insert allied health referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
7. Counselled on: [Insert counselling topics discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
8. Follow-up instructions: [Insert follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Tasks to be created:
[Insert tasks such as referrals, letters, results to review, or information to request] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, assessments, diagnoses, plans, interventions, evaluations, or follow-up actions—use only the transcript, contextual notes, or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing; simply omit the placeholder or section entirely.)
