Audio_Gynec_Hp_29

HISTORY: This is a 52-year-old female, G2, P2 who presents today because she has been spotting for the past two weeks. She had a recent workup performed for her bleeding and the workup had revealed a small multiple fibroid uterus with normal biopsy results with some fragments consistent with a polyp and hormone levels in the non-menopausal range. She also has associated pelvic discomfort.

PHYSICAL EXAMINATION: Abdomen: Soft, nontender, nondistended. Pelvic examination: Vagina: No lesions are noted. Cervix: Her os is closed with a slight menstrual type stain noted. Uterus: Enlarged and bulky approximately 12-week size. Adnexa: Nontender. No masses are appreciated.

ASSESSMENT: Perimenopausal bleeding with a fibroid uterus with mild symptoms associated with her fibroid uterus.

PLAN: Discussed all of the above again with the patient and her husband. They were given literature in the past on hysterectomy. However, at this time, she is not sure whether or not she would want to have this procedure performed at this time. We did discuss other options of performing an outpatient dilatation and curettage with a diagnostic hysteroscopy. However, the patient was told that this procedure would not be definitive and may only help temporarily with the bleeding at best and will not take away her pelvic discomfort. The risks versus the benefits of the procedure were explained her to her and her husband. There were given literature on dilatation and curettage and hysteroscopy. She also will consider again possibly having a hysterectomy performed at a later date and she will return when she is ready to schedule for either procedure and/or to discuss management options further. All of their questions were answered and they agreed with the management.