Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
Describe the patient’s main reason for presentation, typically involving:
Heavy menstrual bleeding (menorrhagia)
Pelvic pain (may worsen during menstruation)
Dysmenorrhea (painful menstruation)
Pain during intercourse (dyspareunia)
May also be asymptomatic in some cases.
History of Present Illness:
Onset, duration, and severity of symptoms
Menstrual history (cycle length, regularity, bleeding patterns)
Past medical history (uterine surgeries, gynecological conditions)
Past treatments for adenomyosis or menstrual problems (medications, procedures)
Pregnancy history (number of pregnancies, deliveries, and any complications)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be normal unless anemia is present from heavy bleeding.
General examination: Assess for signs of anemia (pale skin, fatigue).
Pelvic examination:
Uterus size and tenderness (may be enlarged and tender in some cases).
Adnexal tenderness (tenderness in the ovaries or fallopian tubes) – less common in adenomyosis.
Imaging Studies (may be ordered to confirm diagnosis or rule out other causes):
Ultrasound: May show a thickened uterine junctional zone (where the endometrium meets the myometrium) – suggestive but not diagnostic of adenomyosis.
MRI (Magnetic Resonance Imaging): More accurate for diagnosing adenomyosis by visualizing the extent of endometrial tissue within the myometrium.
Laboratory Findings (may be ordered to assess for anemia):
Complete blood count (CBC): May reveal anemia if heavy menstrual bleeding is present.
Assessment:
Based on clinical presentation (symptoms and menstrual history) and imaging studies (if available), diagnose adenomyosis.
Consider the severity of symptoms and impact on quality of life.
If imaging is not performed, describe the clinical suspicion for adenomyosis.
Plan:
Treatment options depend on the severity of symptoms, desire for future pregnancy, and age of the patient.
Medical management:
Hormonal birth control pills or injections can regulate menstrual cycles and reduce bleeding.
Non-steroidal anti-inflammatory drugs (NSAIDs) to help manage pain.
Gonadotropin-releasing hormone (GnRH) agonists: May be used to shrink fibroids and induce temporary menopause (not ideal for long-term use due to side effects).
Minimally invasive procedures:
Endometrial ablation (destruction of the endometrial lining) – may not be effective for adenomyosis as the endometrial tissue is within the muscle layer.
Myolysis (destruction of uterine tissue) – performed with laparoscopy or hysteroscopy, may have limited long-term benefit.
Surgery:
Hysterectomy (removal of the uterus) – definitive treatment but not ideal for women who desire future pregnancy.
Consultations (may be needed depending on the treatment plan):
Reproductive endocrinologist (for hormonal management)
Minimally invasive surgeon (for procedures like myolysis)
Gynecologic surgeon (for hysterectomy)
Progress Notes:
Document response to treatment, including changes in bleeding patterns, pain levels, and overall well-being.
Monitor for side effects of medications.
If considering surgery, discuss risks, benefits, and alternative options with the patient.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis and a personalized treatment plan are crucial for managing adenomyosis and improving the patient’s quality of life.