ABD OBGYN HEAVY PERIODS

HPI: 25 YO FEMALE C/O HEAVY PERIODS FOR 1 MONTH. PELVIC PAIN 6/10
INTENSITY, NONRADIATING, SHARP IN QUALITY, STARTED 1 MONTH AGO,
LAST 4-5 HOURS, EVERY DAY, WITH NO CHANGES, AGGRAVATED BY
CONSTIPATION, RELIVED BY DEFECATION. PERIODS WERE NORMAL UP
UNTIL ONE MOTH AGO, PATIENT REPORTS GOLF BALL SIZE CLOTS EACH
DAY, USING 8 PADS A DAY. FATIGUE, DYSPNEA WITH EXERTIONS,
DIZZINESS AND LIGHTHEADED NESS WHEN MOVING QUICKLY.

-PATIENT DENIES FEVER, CHILLS, DYSURIA, DISCHARGE OR TRAUMA

-OBGYN: MENARCHE AGE 13, LMP IS IN PROGRESS, LPS 1 YEAR AGO

NORMAL, NO CHILDREN, NO PREGNANCIES, NO HISTORY OF STDS,

-ROS: NEGATIVE EXCEPT AS NOTED ABOVE

-ALLERGIES: NONE
-MED: NONE
-PMH: NO PREVIOUS EPISODES OF CHIEF COMPLAINT
-PSH: APPENDECTOMY 5YRS AGO
-FH: PARENTS ALIVE AND WELL, MOTHER HAD UTERINE FIBROIDS 20YRS
AGO
-SH: SMOKES 1PPD FOR 6YEARS, DRINKS OCCASIONALLY 1 GLASS A WINE -
PER MONTH, DENIES DRUG USE, IS A COLLEGE STUDENT IN NURSING,
LIVES WITH PARENTS. SEXUALLY ACTIVE WITH BOYFRIEND OF 6 MONTHS
DOES NOT USE CONDOMS.

PHYSICAL EXAM
GA: PATIENT IS PALE AND LETHARGIC
VS: WNL
HEENT: NORMCEPHALIC, ATRAUMATIC
NECK: SUPPLE, NO LAD, NO JVD, NO BRUITS
MOUTH: CLEAR
HEART: RRR, S1 S2 NORMAL
LUNG: CTAB
ABDOMEN: SUPRAPUBIC TENDERNESS, BS+, NEGATIVE REBOUND,
NEGATIVE CVA TENDERNESS.
EXTREMITIES: NO EDEMA, NO BRUISING
NEURO: GAIT NORMAL

DD:
ADENOMYOSIS
UTERINE FIBROIDS
ENDOMETRIOSIS
CERVICAL CANCER
ECTOPIC PREGNANCY
WORK UP
PELVIC EXAM
LAPAROSCOPY
CERVICAL CULTURES/PAP SMEAR
PELVIC/UTERINE US
CBC/UA