Abnormal uterine bleeding

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.