OB-GYN_5
OB-GYN_6
OB-GYN_7
OB-GYN_8
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.
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.
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.
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