Patient presents with complaints consistent with uterine fibroids, including heavy menstrual bleeding (menorrhagia), prolonged menstrual periods (hypermenorrhea), pelvic pressure or pain, and urinary frequency.  Symptoms impact quality of life, interfering with daily activities and causing significant discomfort.  Physical examination reveals an enlarged, irregular uterus palpable on bimanual exam.  Pelvic ultrasound confirms the presence of uterine leiomyomas, consistent with the diagnosis of uterine fibroids.  The size, number, and location of the fibroids are documented.  Differential diagnoses considered include adenomyosis, uterine polyps, and ovarian cysts.  Assessment includes evaluation of hemoglobin and hematocrit levels to assess for anemia secondary to heavy menstrual bleeding.  Treatment options discussed include watchful waiting, medical management with hormonal therapy such as gonadotropin-releasing hormone agonists (GnRH agonists) or oral contraceptives, and surgical interventions such as myomectomy or hysterectomy.  Risks and benefits of each treatment option were explained to the patient.  Patient education provided on uterine fibroid symptoms, treatment options, and potential complications.  Follow-up scheduled to monitor symptom progression and treatment response.  ICD-10 code D25.9 (Leiomyoma of uterus, unspecified) is assigned.  CPT codes for procedures performed, such as pelvic ultrasound (76830) or endometrial biopsy (58100, if performed), will be documented separately.  Medical necessity for treatment and imaging studies is documented.