History of Presenting Complaint (HPC):
- Jane Doe, a 32-year-old female, presents with abnormal uterine bleeding for the past 3 months. The bleeding is heavy, lasting for 10 days each cycle, and is associated with severe cramping. The onset was gradual.
- Associated symptoms include fatigue and dizziness.
Past Medical History:
- History of abnormal uterine bleeding 2 years ago, resolved with hormonal therapy.
- No history of bleeding disorders.
- Past medical history includes hypothyroidism and appendectomy in 2015.
Medications and Allergies:
- Levothyroxine 50 mcg daily for hypothyroidism, started 3 years ago.
- No known allergies.
Family History:
- Mother had a history of heavy menstrual bleeding and was diagnosed with fibroids.
Screening Questions:
- Menstruation:
- Currently in the luteal phase of her cycle.
- Menstrual cycle length is 28 days, regular.
- Bleeding lasts for 10 days, with heavy volume requiring frequent pad changes.
- Menarche at age 12.
- Change of Pregnancy:
- No possibility of pregnancy; last sexual intercourse was 6 months ago, and she has been using contraception consistently.
- Previous Pregnancies:
- G2P2, both pregnancies resulted in full-term vaginal deliveries.
- No current plans for future pregnancies.
- Contraception:
- Currently using an intrauterine device (IUD) for the past 2 years.
- No missed pills as she is using an IUD.
- Menopause Status:
- Pre-menopausal.
- No use of hormone replacement therapy.
- Sexual History:
- Sexually active with one partner, no history of sexually transmitted infections (STIs).
Review of Systems (ROS):
- Reports fatigue and dizziness. No urinary changes or bowel changes.
Examination:
- General Examination:
- Vital signs stable, no pallor or jaundice noted.
- Pelvic Examination:
- Uterus slightly enlarged, tenderness noted on palpation.
- Speculum Examination:
- Cervix appears normal, no lesions or discharge noted.
Investigations:
- Complete blood count (CBC) shows mild anemia (Hemoglobin: 10.5 g/dL).
- Pelvic ultrasound reveals a small fibroid in the uterine wall.
Assessment and Plan:
- Clinical assessment suggests abnormal uterine bleeding likely due to a small fibroid.
- Differential diagnoses include hormonal imbalance and endometrial hyperplasia.
- Management plan includes starting tranexamic acid for bleeding control, iron supplements for anemia, and follow-up in 3 months to reassess symptoms and consider further intervention if necessary.
