Vaginal Bleeding

HISTORY:

Abnormal vaginal bleeding for ‍ ‍hoursdays

Type: ‍excessive menstrual bleeding, ‍intermenstrual bleeding, ‍spotting, ‍short cycles (< 21 days), ‍postcoital bleeding

Volume: ‍spottinglightmoderateheavy, ‍with smallwith largewithout clots, changing pads/tampons every ‍ hours

Pattern: ‍constantintermittent

Episodes: lasts for ‍ days, recur ‍ times per ‍weeksmonths

Alleviating factors: ‍none, ‍effectiveineffective

‍vaginal discharge, ‍clear, ‍thin

‍fishy smell

‍pelvic pain

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍vaginal pruritus

‍vulvovaginal rash

‍urinary Sx

‍fatigue



Gynecological history:

Last menstrual period: ‍ ‍daysweeksmonths ago

Menstrual cycles: ‍ days, ‍regularirregular

Menarche: ‍ years old

G‍01234 P‍01234 A‍01234

Last Pap smear: ‍ ‍monthsyears ago ‍never

Coitarche: ‍ years old ‍never

Contraception: ‍yesno ‍oral contraceptives

Condom use: ‍alwayssometimesnever





EXAM:

General appearance: ‍well-appearing

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Pelvic:

- External genitalia: ‍normal, ‍inguinal lymphadenopathy

- Vagina: ‍normal, discharge ‍normal, ‍malodorous

- Cervix: ‍normal

- Uterus: ‍normal, ‍no cervical motion tenderness

- Adnexa: -R ‍normal, -L ‍normal

- Tests performed: ‍Pap test, ‍HPV DNA, ‍vaginal culture, ‍chlamydia/gonorrhea, vaginal pH ‍< 4.5> 4.5, whiff test with KOH ‍negative

- Performed with chaperone



ASSESSMENT:

‍Abnormal uterine bleeding ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍ferritin, ‍coagulation profile, ‍TSH, ‍FSH, ‍PRL, ‍β-hCG

- STI screening for chlamydia and gonorrhea

- Pap smear

- Pelvic ultrasound

- ‍NSAIDs

- ‍Oral contraceptives

- ‍Tranexamic acid

- Oral contraceptives adherence counseling

- Change of progestin in oral contraceptives

- Increase dose of estrogen in oral contraceptives

- Smoking cessation counseling

- Referral to gynecologist

- Follow-up in ‍ ‍weeksmonths

- Return if bleeding worsens or if symptoms do not improve with treatment