Sample Type / Medical Specialty: Consult - History and Phy. Description: Pelvic Pain and vaginal discharge
Sample Name: OB/GYN Consultation - 4
(Medical Transcription Sample Report)
CHIEF COMPLAINT - REASON FOR VISIT: Pelvic Pain and vaginal discharge.
ABNORMAL PAP HISTORY: Date of abnormal pap: 1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.
PELVIC PAIN HISTORY: The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable. Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.
VAGINITIS HISTORY: Symptoms have lasted for 2 weeks and persistent. Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.
PERSONAL / SOCIAL HISTORY: Tobacco history: Smoke’s 1 pack of cigarettes per day. Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.
PAST MEDICAL HISTORY: Negative.
FAMILY MEDICAL HISTORY: Negative.
ALLERGIES: No known drug allergies/Intolerances.
CURRENT MEDICATIONS: There are no current medications.
PAST SURGICAL HISTORY: D & C. 1993
REVIEW OF SYSTEMS:
Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.
Genitourinary: Patient denies any genitourinary problems.
Gynecological: Refer to current history.
Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.
GU: Denies frequency, nocturia and hematuria.
Neuro: Denies any problems, no seizures, no numbness, no dizziness.
Vital Signs: Weight: 104. BP: 100/70.
Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.
Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.
Breast: No palpable masses. No dimpling or retraction. No discharge. No axillary lymphadenopathy.
Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.
Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery. Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender.
Rectal: No additional findings.
LAB / TESTS: Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood
IMPRESSION / DIAGNOSIS
1. Endometritis / Endomyometritis (615.9).
2. Cervicitis - Endocervicitis (616.0).
3. Pelvic Pain (625.9).
PLAN: Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.
MEDICATIONS PRESCRIBED: Metronidazole 500 mg #14 1 BID for 7 days. Doxycycline 100 mg #14 1 BID.
consult - history and phy., vaginal discharge, pelvic pain, pap, colposcopic exam, dysplasia, endometritis, endomyometritis, endocervicitis, cervicitis, pap smear, consultation, gynecological, uterus, intraepithelial, vaginal, pelvic,
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