OB-GYN FILES

OB-GYN_5

CHART NOTE

The verbal report of the cervical biopsies was positive for large-cell carcinoma with both deep margins positive.  Will arrange to have all slides sent to the office, and they can either be sent or hand carried.  Have asked her to schedule an abdominopelvic CT scan and also a chest x-ray and mammogram.

Will need to be able to take all these films with her for her referral appointment.  If she has any questions, she has to call.

CHART NOTE

Comes in today for annual examination.  Her son is a little over a year old and doing well.  She usually has a menstrual period about every month, has totally missed1; menses do tend at times to be somewhat irregular.  She is late for her current period but feels as if she is going to get one soon.  She has no intermenstrual bleeding.  This is the same pattern as menses were prior to becoming pregnant the first time.

First pregnancy was complicated by preeclampsia, Pitocin induction of labor at 37-1/2 weeks.  Her son weighed 6 pounds 8 ounces and did well.  Blood pressure was persistently elevated postpartum, and at 6-week examination was 150/86.  For this reason she did not use oral contraceptive pills but has used foam and condoms for contraception.  She would like to become pregnant again.  I have told her that it is not likely that she will have preeclampsia again, but she may have some problems with hypertension.

EXAMINATION:  Breasts without masses or nipple discharge.  Abdomen soft and nontender without masses or organomegaly.  Pelvic examination reveals external genitalia are normal.  Vagina rugous.  Cervix clean.  Uterus is of normal size, shape, and consistency.  Adnexa clear, nontender.  Rectovaginal examination confirms.

Pap smear was obtained.

ASSESSMENT:  Normal examination, considering another pregnancy.

PLAN:  Follow up in a year or sooner if pregnant.

CHART NOTE

Comes in today for annual examination.  Menses are regular without intermenstrual bleeding.  Her galactorrhea is unchanged.  She continues to take bromocriptine 2.5 mg daily and also daily potassium supplement.  When seen a year ago, she felt fatigued.  Blood work at that time showed her to be hypokalemic.  She resumed a potassium supplement at that time, and felt much better.  She has no headaches.  She had some vaginal itching and discharge off and on during the summer but currently does not have any.  She has never had a mammogram.

EXAMINATION:  Breasts without masses.  There is bilateral galactorrhea.  There was no axillary adenopathty.  Abdomen soft and nontender.  Pelvic examination reveals external genitalia are normal.  Vagina rugous with small amount of yellow discharge.  Cervix clean.  Uterus is anterior, mobile, nontender; normal size, shape, and consistency.  Adnexa clear, nontender.  Rectovaginal examination confirms.

Pap smear is obtained.

Wet smear is unremarkable.

ASSESSMENT

1.  Long history of galactorrhea.  Prolactins have been well controlled on Parlodel, as have her menses.

2.  Has taken chlorthalidone daily for many years.  This is for fluid retention.

PLAN

1.  Parlodel 2.5 mg p.o. b.i.d. is renewed for a year.

2.  Chlorthalidone 50 mg daily and potassium supplement 1 daily is renewed.

3.  Serum prolactin and serum potassium levels are obtained.

CHART NOTE

Comes in today for annual examination.  On hormone replacement therapy consisting of Premarin 0.625 mg days 1 through 25, and Provera 10 mg days 16 through 25.  She has regular withdrawal bleeds, which are not heavy, and has no bleeding or spotting at any other time.

EXAMINATION:  Breasts without masses or nipple discharge.  Abdomen soft and nontender without masses or organomegaly.  Pelvic examination reveals external genitalia are normal.  Vagina rugous.  Cervix clean.  Uterus is normal size, shape, and consistency, slightly deviated to the left.  Adnexa clear, nontender.  Rectovaginal examination confirms.

PLAN:  Have offered to change her to continuous Premarin and Provera, but she is satisfied with her current regimen, and will continue with it as described above.  Follow-up will be in a year.

OB-GYN_6

DISCHARGE SUMMARY

A 24-year-old white female, single, admitted as an emergency case for exploratory laparotomy for possible tubal pregnancy with delayed menses, positive serum hCG x 2, and a pelvic ultrasound showing empty uterus with a bilateral adnexal masses, the right larger than the left.

She underwent dilatation curettage, exploratory laparotomy with excisional biopsy of growths on both right and left ovaries, drainage of right ovarian cyst.

Frozen section diagnosis benign ovarian cystadenoma.

Her hCG was done with quantitative analysis on day 1 postoperatively with subsequent results of 298.

Her final pathology report on the ovarian tissues showed benign serous surface papillomas (adenofibroma) with benign secretory endometrium with deciduoid reaction.

Her final hemoglobin postoperatively was 12.1.  To be followed in the office for the remainder of her postoperative care.  She did have a cystitis that was present prior to surgery, and this responded to amplicillin orally.

FINAL DIAGNOSIS

1.  Benign serous surface papillomas (adenofibroma) of both right and left ovaries.

2.  Folicular cyst, right ovary.

3.  Cystitis.

SURGERIES PERFORMED:  Exploratory laparotomy.  Excisional biopsy, right and left ovaries.  Drainage of right ovarian cyst.

OB-GYN_7

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT:  Uterine prolapse.

HISTORY OF PRESENT ILLNESS:  This is a 64-year-oldl woman who is para 4, who was referred because of a large cystocele and uterine prolapse.  The patient states that when she is on her feet, a bulge comes out of the vagina between her legs.  She was found to have a large cystocele and a second-degree uterine prolapse, the cervix protruding through the os even with the patient lying down, when she strains.  She does not have any significant problem with urinary tract control.  She enters at this time for vaginal hysterectomy and A&P repair.

PAST HISTORY:  Her general health has been reasonably good.  She is taking Lanoxin 0.25 mg 1/2 tablet per day.

PHYSICAL EXAMINATION

GENERAL:  Physical examination reveals a well-developed, well-nourished, slender white female at 131 pounds.  Blood pressure is 130/70.

HEENT:  Ears negative.  Eyes:  Pupils small, react well to light.  Sclerae clear.  Mouth:  I believe the patient has dentures.  The throat is clear.  Tonsils are absent.

NECK:  Supple.  No masses felt.

BREASTS:  Quite good turgor for her age.  No masses are felt.

LUNGS:  Lungs are clear to P&A.

HEART:  Regular rhythm, no murmur.

ABDOMEN:  The abdomen is soft and nontender.

GYNECOLOGIC EXAMINATION:  On gynecologic examination, there is relaxation.  When the patient strains, the bladder bulges down and out and the cervix comes out through the introitus.

RECTAL:  Rectal is negative.  No intrinsic masses.  Moderate rectocele.

EXTREMITIES:  Mo significant deformities are noted.  No edema.  Reflexes are physiologic.

IMPRESSION:  Second-degree uterine prolapse.  Cystocele with some rectocele.

PLAN:  Plan is for vaginal hysterectomy, anterior repair, and possibly posterior repair at the same time.

OB-GYN_8

LETTER

Date

Name

Address

City, State, Zip

Gentlemen

At the request of my patient, I am forwarding this brief medical report.

HISTORY:  This 42-year-old woman was seen in consultation regarding problems referable to her right and left breasts.

This patient has a long history of bilateral fibrocystic disease with episodes of mastitis in both breasts.

The patient underwent a bilateral subcutaneous mastectomy with implant reconstruction.  Subsequently, because of complications with contractures, these implants were removed.  The patient developed a lump in her right breast, which was diagnosed as a probable recurrent cyst near the axilla.  This was followed for almost 1 year without change.  However, the lump became somewhat tender.  Examination revealed some ill-defined induraton in the upper outer quadrant of the right breast flap.  Old incisional scars were noted in both breasts.

DIAGNOSES

1.  Probable residual fibrocystic disease in the upper outer quadrant of the right breast.

2.  Status postoperative bilateral subcutaneous mastectomy.

COMMENTS:

1.  The patient is seeking consultation both in regard to the induration in the upper outer quadrant of the right breast as well as for possible reconstructive surgery to the both breasts.  She has never fully accepted the resection of the breast tissue and the loss of the implant reconstruction.

2.  I have suggested to the patient that we could consider at this point in time removal of the area of induration from the upper outer quadrant of the right breast, which is so tender, as well as performing an implant reconstruction of the right and left breasts using polyurethane-type implants.

3.  The patient would appreciate a letter of stating that this would be covered under her group health insurance program.

4.  I have included a copy of the pathology report from the tissue resected.

Sincerely

Name.