OB-GYN TEST FILES

OB-GYN_T1

OB-GYN CHART NOTE

SUBJECTIVE:  This is a 19-year-old single white female college student who is seen with reference to vulvar pain and urinary burning of 2 to 2-1/2 days’ duration.  She denies any prior GU infections.  She is sexually active with multiple partners but seldom uses condoms.  She is on oral contraceptive.  Gravida 0.  LMP about 2 weeks ago.  She noted onset of vulvar itching and burning on Monday afternoon associated with pain on voiding.  This has become steadily worse to the point where she can now hardly void at all.  She thinks she may have had some fever last night.  She has noted slight increase in vaginal discharge.  She has had no urinary frequency, no blood in the urine, no flank pain, chills, nausea, but she has been anorexic.  Some headaches in the past 24 hours.  She is on no medicine except Demulen, and Advil for her pain, which is not helping.

OBJECTIVE:  This is a very distraught young lady.  She is tearful and obviously in considerable physical and mental distress.  Temperature is 99.8, pulse 100, blood pressure 132/78.  Her skin is pale, warm, and dry.  Examination limited to the genitourinary system reveals a cluster of shallow, discrete ulcers on the left labium minus, and these are surrounded by an angry erythema, and their bases are covered with a shaggy, grayish exudate.  There is generalized edema and erythema of the vulva.  There is a moderate amount of excessive secretion at the introitus, nonspecific in character.  Several tender lymph nodes are palpable in both groins.  Bimanual examination is deferred because of the severity of the patient’s symptoms at this time.  However, abdominal examination shows no bladder distention.  Scrapings are taken from 2 ulcers with a #15 blade and smeared and stained immediately by the Tzanck technique with toluidine O.  Examination of the smear shows giant cell formation typical of viral infection.

ASSESSMENT:  Herpes simplex virus infection, left labium minus, type II, probably primary.

PLAN

1.  The diagnosis and its implication were fully discussed with the patient, in association with a female counselor, and she was given printed literature to take with her.  She was advised that she is presently infectious and must abstain from sexual contact until she is well.  She was advised that recurrences are not invariable and that she may not have any.  She was advised that should she have a recurrence, she will again be infectious, but that recurrences are typically milder than the primary infection. She was advised that she has an increased risk of cervical dysplasia and neoplasia and needs annual Pap smears from here on out.  She was advised that should she have a recurrence near term of pregnancy, she would need cesarean section.  She was advised to inform any prospective marriage partner of her diagnosis.  Though obviously upset, she verbalized comprehension of these instructions.  She was given some further counseling by the counselor after I left the room and will be seen in follow-up by them and as well as by me on a p.r.n. basis.

2.  Zovirax 200 mg p.o. q.4h. for 5 doses a day x 10 days.

3.  Tylenol No. 3 one or 2 tabs q.4-6h. p.r.n. for pain.

4.  Zinc oxide ointment to be applied to the lesions as often as needed to prevent urinary burning, protecting the finger with a finger cot or condom.

5.  She is to watch bladder function and to call the clinic day or night if she cannot void.

6.  She will be scheduled back here in 1 to 2 weeks for pelvic examination, Pap smear, and STD screen, including Thayer-Martin, Chlamydia slide test, and a wet mount for Candida, Gardnerella, and Trichomonas.

OB-GYN_T2

OB-GYN 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 missed 1; 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 p.o. b.i.d.  She takes chlorthalidone 50 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 adenopathy.  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.