Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with abnormal uterine bleeding (AUB), characterized by [menorrhagia/metrorrhagia/postmenopausal bleeding]. Onset: [Date/Duration]. Frequency: [Number of days/cycles]. Associated symptoms: [pelvic pain/pressure/dysmenorrhea]. Risk factors: [obesity/PCOS/unopposed estrogen therapy/tamoxifen use/family history]. No history of recent hormonal changes or prior endometrial sampling.
Clinical Examination Findings
Abdominal exam: Soft, non-tender, no palpable masses or organomegaly. Pelvic exam: External genitalia normal. Speculum exam: Cervix appears healthy, no active bleeding noted at the os. Bimanual exam: Uterus [size/position], mobile, non-tender. Adnexa: No palpable masses or tenderness.
Treatment Protocol
Plan: 1. Endometrial biopsy (EMB) performed/scheduled to rule out malignancy. 2. Transvaginal ultrasound (TVUS) to assess endometrial thickness (ET). 3. Pharmacologic management: [Progestin therapy/Levonorgestrel IUD]. 4. Follow-up: Repeat endometrial sampling in [3-6] months to assess treatment response. 5. Surgical consultation: Consider hysteroscopy with D&C if symptoms persist or biopsy is inconclusive.