HISTORY:
Irregular periods for
Cycle: days
Onset: , occurred after
Pattern:
Menstrual flow: , clots
, , ,
, over
, over ,
Gynecological history:
Menarche: years old
Contraception: ,
Condom use:
G P A
Menopausal status:
Other elements:
EXAM:
General appearance:
Breasts: -R: , -L:
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , on day 3 of cycle, , ,
- Pelvic ultrasound
- Pelvic MRI
- Progestin challenge test: Medroxyprogesterone 10mg po for 10 days (if bleeding occurs, anovulation is confirmed)
- Endometrial biopsy
- Lifestyle modifications: , , , , ,
-
-
-
- Referral to gynecologist
- Referral to endocrinologist
- Follow-up in
- Return if menstrual irregularity persists, if new symptoms develop such as heavy bleeding or pelvic pain, or if symptoms do not improve with treatment
- Go to ER if severe abdominal pain or heavy bleeding occurs