General Gynaecology Intake

Subjective:
Chief Complaint:
Prolonged bleeding and cramps on Depo shot

History of Present Illness:
Emily presents with a history of prolonged vaginal bleeding and dysmenorrhea while receiving depot medroxyprogesterone acetate injections for contraception. She reports that beginning January 19th, she experienced continuous vaginal bleeding lasting approximately one month. Following her most recent injection at the beginning of this month, she describes only occasional spotting but persistent severe lower abdominal cramping. Emily has been using depot medroxyprogesterone acetate since 2021. She has a history of endometriosis, for which she underwent two laparoscopic procedures within the past two years. She also reports a history of two spontaneous abortions, with the most recent occurring in September. Her last Papanicolaou test was in 2021, and a pelvic ultrasound performed in April demonstrated a normal endometrial lining measuring six millimeters. She denies any other significant gynecologic history. Emily has a medical history of rheumatoid arthritis, currently managed with methadone. She reports an allergy to penicillin, tobacco use, and no alcohol consumption. Family history is notable for an aunt with breast carcinoma. She has two children, both delivered vaginally without complications.

Obstetric History:
Emily has a history of two full-term pregnancies, both resulting in vaginal deliveries without complications. She also reports two spontaneous abortions, with the most recent occurring in September.

Gynaecological History:
Emily has a history of endometriosis, for which she underwent two laparoscopic procedures within the past two years. She has been using depot medroxyprogesterone acetate for contraception since 2021. Her last Papanicolaou test was performed in 2021. She reports prolonged vaginal bleeding and dysmenorrhea while on depot medroxyprogesterone acetate. A pelvic ultrasound performed in April demonstrated a normal endometrial lining measuring six millimeters.

Past Medical History:
Emily has a diagnosis of rheumatoid arthritis.

Past Surgical History:
Emily underwent two laparoscopic procedures for endometriosis within the past two years.

Family History:
Emily's paternal aunt had breast carcinoma.

Social History:
Emily reports tobacco use and denies alcohol consumption.

The Review of Systems:
Constitutional – no Fever, Chills, Weight Loss, Weight Gain, Night sweats, Fatigue, or Weakness
Eyes – no double vision, no blurry vision, wears glasses
ENT – no Hearing loss, dizziness, runny nose, nose bleeds, nasal septum deviation, or sore throat
Integumentary – no rashes, dry skin, or eczema
Cardiovascular – no chest pain, heart palpitations, dizziness
Respiratory – no shortness of breath, no cough, no wheezing
Endocrine – No known thyroid issues, no changes to appetite, no weight change, no tiredness/lethargy
Gastrointestinal – No nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating.
Genito Urinary – no Dysuria, hematuria, frequency, urgency.
Musculoskeletal – no joint tenderness, redness or swelling
Neurological – No headaches or weakness, no history of seizures
Psychology – No changes in mood, no anxiety
Hematology – Denies easy bruising

Current Medications:
Emily is currently taking methadone.

Allergies:
Emily reports an allergy to penicillin.

Gynecologic History:
Emily underwent her last Papanicolaou test in 2021, with the next screening due in September. She has a history of endometriosis, for which she has undergone two laparoscopic procedures within the past two years. She has utilized depot medroxyprogesterone acetate for contraception since 2021. A pelvic ultrasound performed in April demonstrated a normal endometrial lining measuring six millimeters. She has a history of two spontaneous abortions, with the most recent occurring in September. Emily has two children, both delivered vaginally without complications. She reports an allergy to penicillin, tobacco use, and no alcohol consumption. Family history is notable for an aunt with breast carcinoma.

Objective:
Physical Examination:
General – Appears well, no obvious discomfort
ENT – No cervical lymphadenopathy, throat normal with no erythema or exudates.
Cardiovascular – Heart rate regular, S1S2 normal with no murmurs or added sounds, peripheral pulses easily palpable, equal and symmetric, normal capillary refill, no JVD, no carotid bruits, no central or peripheral cyanosis, no clubbing, no peripheral edema.
Respiratory – Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion.
Skin – No rashes, no dry skin, no skin infections
Breasts: Normal symmetrical appearance, no erythema, skin changes or tethering, no inverted nipples. Non-tender normal breast tissue on palpation with no palpable masses. Normal axillary lymph nodes on palpation.
Abdomen – Normal bowel sounds, abdomen soft and non-tender, no distension.
Genito Urinary – External genitalia normal, no inguinal adenopathy, normal pelvic examination
Musculoskeletal – No tender, swollen, warm, or erythematous joints. Normal range of motion in examined limbs, no muscle tenderness.
Neurological – Alert and oriented in time, space and person, normal gait, strength 5/5 in upper and lower limbs, CN 2-12 grossly intact, coordination intact.

Test Results:
A pelvic ultrasound performed in April demonstrated a normal endometrial lining measuring six millimeters. Uterine lining appears very thin on biopsy, likely due to depot medroxyprogesterone acetate.

Assessment:
Problem:
Abnormal uterine and vaginal bleeding, unspecified (N93.9) while on depot medroxyprogesterone acetate, with a history of endometriosis and recent uterine lining biopsy showing thin endometrium.

Differential Diagnosis:
Abnormal uterine bleeding secondary to depot medroxyprogesterone acetate, endometrial atrophy, recurrence of endometriosis, or sequelae of recent spontaneous abortion.

Plan:
Orders and Referrals: Uterine lining biopsy performed.
Treatments: No new medications or interventions prescribed during this visit.
Patient Education: Emily was informed that the thin endometrial lining is likely due to depot medroxyprogesterone acetate and is not concerning at this time.
Follow Up: Await biopsy results in three weeks.

Clinic Name: [Clinic Name]