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-=-=-=-=-=> [這篇文章最後由JuanFe在 2018/05/11 07:13pm 第 1 次編輯] VAGINAL BLEEDING Doorway information about patient The patient is a 20 - year - old woman who reports abnormal vaginal bleeding. Vital signs . Temperature 36.7’C . Blood pressure 110/70 mmHg . pulse : 80 /min . Respirations : 16/ min Approach to the patient Abnormal uterine bleeding (AUB) is bleeding that is heavy , lasts > 7 days , or occurs more than every 21 days or less than every 35 days . AUB may be heavy bleeding during a normal cycle (eg, uterine leiomyomas ) , bleeding between menses (eg, endometrial hyperplasia ) , or irregular bleeding ( eg, polycystic ovarian syndrome) . AUB should be differentiated form bleeding form other sources ; heavy bleeding is usually form the endometrium , wheres light spotting can be form either the endometrium or other genitourinary sites(eg , cervix , vagina ) . Postcoital bleeding is usually form the cervix or vaginal mucosa . Occasionally , woman who report vaginal bleeding actually have hematuria or rectal bleeding . Prolonged oligomenorrhea suggest chronic an ovulation and increase the risk of abnormal endometrial proliferation . Endometrial hyperplasia or malignancy is a concern with AUB in patient age >=45 , especially postmenopausal woman (>12 months since the last menstrual period [LMP]). Different diagnosis Causes of abnormal uterine bleeding in non pregnancy women STRUCTURAL CAUSES Polyp(eg, endometrial polyp) Adenomyosis Leiomyoma(submucosal & other) Malignancy & hyperplasia NONSTRUCTURAL CAUSES Coagulopathy Ovulation dysfunction Endometrial ( eg, infection , inflammation ) Iatrogenic (eg, anticoagulants) Not yet classified pregnancy and pregnancy- related complications (eg, placenta; abruption , ectopic pregnancy ) should be considered in all premenopausal woman with AUB . After pregnancy is ruled out , AUB may be classified according to structural or nonstructural causes. History and physical examination HISTORY HISTORY OF PRESENT ILLNESS . when did the bleeding start ? . Was the onset gradual or sudden? . Can you describe the bleeding (eg, bright red blood , brown spotting , clots) . Is the bleeding continuous or intermittent ? . How many tampons / pads do you use a day ? . Did you pass any tissue ? (eg , roar pregnancy ) . Do you have otters symptoms beside bleeding ? (* eg , abdominal pain , fever , vomiting ) ? . Have you ever been pregnant ? . Describe your typical cycle : often , regular , days , heavy (tampons / pads ) . Have you had any portions or miscarriages? . Have you noticed sores , pain , or infection around the genital area ? —sexual history — . Are you sexually active now ? in the past ? . Are you using birth control ? what type ? ( Copper intrauterine devices are associated with increased bleeding ) . Have you had pain or bleeding with intercourse ? . have you ever had a sexually transmitted infection ? PAST MEDICAL HISTORY . have you ever had abnormal bleeding ? . Have you had liver or kidney disorders ? MEDICATIONS . Are you taking medications (eg . aspirin , nonsteroidal anti inflammatory drugs, anticoagulants ?) FAMILY HISTORY . Do you have a family history of bleeding disorders? . Has anyone in your family had recurrent miscarriages? SOCIAL HISTORY . Do you smoke ? . Do you drink alcohol? . Do you use illicit drugs ? (cocaine may cause bleeding ) All patients with AUB should have a pelvic examination . However , pelvic examinations are not permitted in the USMLE step 2 CS exam , but should be listed in the Diagnostic Studies section of our cases documentation. PHYSICAL EXAMINATION General . Body habits (eg , obesity , low body weight) HEENT . Other sites of bleeding ( eg . nasal mucosa , gums ) Skin . Petechiae or purpura . Hair distribution & quality ( eg , hirsutism , fine lanugo hair ) Abdomen . Distension . Bowel sound . Liver & spleen size . Abdominal ( including suprapubic ) masses or tenderness Closing the encounter the causes of AUB is usually not confirmed sole on clinical findings , especially in he step 2 CS exam as pelvic examination is not permitted . The wrap - up discussion should discuss the most likely causes and the tests need ed to confirm the diagnosis . Because many of these studies are either physically uncomfortable (eg, transvaginal ultrasound) or of a personally sensitive nature (eg. pregnancy test ) , allow the patient to ask questions and obtain permission before proceeding . Diagnostic studies Initial evaluation should include a urine pregnancy test , complete blood count , and coagulation studies . Other laboratory studies to consider include . TSH , prolactin and FSH . Transvaginal ultrasound should be done in most cases to evaluate for structural lesions. indicators of endometrial biopsy include age >=45 with suspected anovulatory bleeding and age < 45 with ovulatory dysfunction and risk factors for unopposed estrogen ( eg, obesity , polycystic ovarian syndrome ) screening for cervical cancer (i.e., Pap test ) should be ordered , if indicated. -=-=-=-=-=>
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