HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT
“I’m here for my surgery.”
HISTORY OF PRESENT ILLNESS
This patient is a 42-year-old white female, gravida 3, para 3. The patient has had considerable trouble with recurrent cervicitis and postcoital bleeding from the cervix. Evaluation has been performed and cryosurgery as well as other procedures accomplished without significant improvement, and she continues to have heavy leukorrhea as well as cervical bleeding on contact and a cervix that reaches the introitus. Over and above this, she has a significant cystourethrocele with stress incontinence and a rectocele. Patient complains of pelvic pressure and postcoital severe pelvic pressure as well as considerable discomfort in the pelvic region whenever she has to sit for a long time. She has been evaluated and seen by a urologist as well as another gynecologist, all of whom concur that she needs definitive surgery for symptomatic pelvic relaxation. The patient is being admitted at this time for this surgery.
PAST HISTORY
Operations: The patient had a cholecystectomy, and she has had cryosurgery of the cervix.
DRUG ALLERGIES
THE PATIENT IS ALLERGIC TO SULFA, WHICH CAUSES A RASH, AND AMPICILLIN, WHICH CAUSES A RASH.
MEDICATIONS
She is on no chronic medications.
PHYSICAL EXAMINATION
VITAL SIGNS: Height 66 inches, weight 138 pounds, blood pressure 110/70.
GENERAL: The patient is a well-developed, well-nourished white female in no acute distress.
HEENT: Negative.
BREASTS: No palpable masses.
HEART: Regular rate and rhythm. No murmurs or rubs.
LUNGS: Clear to auscultation.
ABDOMEN: Normal.
EXTREMITIES AND SPINE: There are some varicosities and a trace of edema.
NEUROLOGIC: Grossly normal.
PELVIC EXAMINATION: There is a second-degree cystourethrocele with loss of urethrovesical angle. The hypertrophic cervix extends to the introitus and bleeds on contact. There is a nearly second-degree rectocele also present. There appears to be an enterocele behind the cervix. The uterus is midposition, an elongated cervix, with a normal fundus. There are no palpable adnexal masses. Rectovaginal examination is confirmatory.
ADMITTING DIAGNOSES
1. Symptomatic pelvic relaxation with hypertrophic cervicitis.
2. Second-degree cystourethrocele.
3. Second-degree uterine descensus.
4. Second-degree rectocele.
5. First-degree enterocele.
FOOTNOTE
Line 10 (Page 1). The heading HPI was translated.
Lines 39-41 (Page 1). The subheadings were added for clarity.
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