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History of Presenting Complaint (HPC): - Patient presents with heavy menstrual bleeding for the past 6 months. Bleeding occurs every 21 days and lasts for 7 days. (SOCRATES: Site - Uterus, Onset - 6 months ago, Character - Heavy bleeding, Radiating - None, Associated symptoms - Fatigue, Timing - Every 21 days, Exacerbating/Relieving factors - None, Severity - 8/10) - Associated symptoms include fatigue and occasional dizziness. Past Medical History: - No past history of abnormal uterine bleeding or gynecological issues. - No history of bleeding disorder. - History of appendectomy at age 16. Medications and Allergies: - Ibuprofen 400mg as needed for pain, Vitamin D 1000 IU daily. - No known allergies. Family History: - Mother had hysterectomy due to fibroids at age 48. Screening Questions: - Menstruation: - Current cycle status: Menstruating. - Menstrual cycle length: 21 days, regular. - Bleeding details: Heavy bleeding, soaking through pads, with clots. - Age at menarche: 12 years old. - Change of Pregnancy: - Assessment details: Not currently pregnant, negative urine pregnancy test. - Previous Pregnancies: - G0P0. - Plans for current or future pregnancies: Patient desires to conceive in the future. - Contraception: - Current contraceptive method: None. - Duration of use: N/A. - Recently missed pills: N/A. - Menopause Status: - Current menopause status: Premenopausal. - Use of hormone replacement therapy: N/A. - Sexual History: - Sexually active with one partner, uses condoms. Review of Systems (ROS): - Reports fatigue and occasional dizziness. Investigations: - CBC: pending. Pelvic ultrasound: pending. SESSION CONTENT: - Patient reports heavy bleeding and fatigue. Discussed potential causes of AUB, including hormonal imbalances and structural abnormalities. - Discussed the importance of ruling out pregnancy and other causes of bleeding. - Discussed the patient's desire to conceive in the future. - Discussed the patient's concerns about her heavy bleeding and its impact on her daily life. - Discussed the patient's medical history and family history. PLAN FOR NEXT SESSION - Next Session: 15 November 2024 at 10:00 AM. - Review lab results and ultrasound findings. Discuss treatment options, including hormonal and non-hormonal approaches. Discuss family planning options. Assessment and Plan: - Assessment: Heavy menstrual bleeding (AUB) likely due to hormonal imbalance or structural cause. Differential diagnoses include fibroids, polyps, and endometrial hyperplasia. Plan: Order CBC and pelvic ultrasound. Discuss treatment options and family planning options at the next visit.