Patient’s Data​

Patient’s name: Aisha Khan

Age: 35-year-old female 

Past medical history:   

• Iron deficiency anaemia secondary to heavy menstrual bleeding 

Drug adn Allergy History  

• Ferrous Sulfate 200 mg once daily
• Microgynon 30 (Recently stopped as requested by patient)
• No known drug allergies

Alerts and QOF

• Cervical screening up to date with no abnormalities on the most recent smear

Recent notes/ consultation

Seen 2 weeks ago by Dr Lucy Aldershot (Clinical Practioner role) 

Presenting complaint: The patient reported experiencing heavy menstrual bleeding since stopping Microgynon 9 months ago, which she discontinued to begin trying for pregnancy. Recent blood tests revealed microcytic anaemia, with a haemoglobin level of 109 g/L. LMP: 2 weeks ago, not currently bleeding. 

Examination: No pelvic tenderness or masses felt. Speculum examination was unremarkable with no abnormalities noted. Blood pressure was 121/65 mmHg and pulse was 70 bpm.

Plan: Ultrasound scan requested. Initiated treatment with ferrous sulfate. Provided safety netting and advice on when to seek further medical attention if symptoms worsen.

Pelvic ultrasound scan report. 

A combined transabdominal and transvaginal pelvic ultrasound scan was performed. A chaperone was present throughout the examination.

The uterus is enlarged with a heterogeneous echotexture. Multiple fibroids are identified, consistent with intramural and subserosal locations. The largest fibroid is seen posteriorly and measures 4.2 cm in diameter. The endometrial thickness appears within normal limits for the reported phase of the menstrual cycle. Both ovaries are visualised and are normal in size and morphology. No adnexal masses or free fluid are observed.

Conclusion:
Ultrasound findings are consistent with multiple uterine fibroids, the largest measuring 4.2 cm. Clinical correlation is advised.

Reported by:
Chinyere Okonkwo
Advanced Reporting Ultrasonographer

Patient booked a telephone consultation to discuss hers can results.