FEMALE:
Presenting Issue:
- The patient presents with concerns about infertility, reporting difficulty conceiving for the past two years despite regular unprotected intercourse. She experiences irregular menstrual cycles and occasional pelvic pain.
Pregnancy Hx:
- The patient has a history of one miscarriage at 8 weeks gestation, no live births, and no abortions.
Parity:
- 1 pregnancy, 0 live births, 1 miscarriage.
TTC:
- The patient has been trying to conceive for 2 years. She has undergone ovulation induction therapy without success.
Complications:
- No complications reported during the previous pregnancy.
Types of delivery:
- Not applicable as there have been no deliveries.
PMHx:
- The patient has a history of hypothyroidism, currently managed with medication.
Menstrual cycle:
- The patient reports irregular menstrual cycles, ranging from 30 to 45 days.
Bleeding:
- Occasional heavy bleeding lasting up to 7 days.
Dyspareunia:
- The patient reports mild dyspareunia, particularly during deep penetration.
Dyschezia:
- No painful bowel movements reported.
Dysuria:
- No painful urination reported.
Premenstrual spotting:
- The patient experiences spotting 2-3 days before menstruation.
Endometriosis:
- Endometriosis is suspected due to pelvic pain and irregular cycles.
CST:
- The most recent cervical screening test was normal, conducted in January 2023.
Anorexia:
- No anorexia reported.
Hypothalamic amenorrhoea:
- Not suspected.
PCOS:
- Polycystic ovary syndrome is suspected based on irregular cycles and ultrasound findings.
Hyper/Hypo-androgenism:
- No signs of androgen imbalance reported.
Urological Hx:
- No significant urological history.
Other conditions:
- None reported.
PSHx:
- Appendectomy in 2015.
Allergies:
- Allergic to penicillin, causing rash.
Medicines:
- Levothyroxine 50 mcg daily.
FMHx:
Maternal:
- Mother has a history of type 2 diabetes.
Paternal:
- Father has a history of hypertension.
SHx:
EtOH:
- Consumes alcohol socially, approximately 2-3 drinks per week.
Smoking:
- Non-smoker.
Rec drug use:
- Denies any recreational drug use.
