CHART NOTE
The patient is here for a gynecologic check. Has menstrual periods usually every 32 to 40 days apart. Last menstrual period was 3 months from the previous one. Normal flow began on
July 17.
July 17.
Bimanual examination is normal. Uterus is symmetrical, normal size. Adnexal areas reveal no masses or thickening. Cul-de-sac is free, and cervix reveals no tenderness.
IMPRESSION
1. A normal gynecologic examination.
2. Oligomenorrhea.
The patient is desirous to become pregnant. If menstrual periods are greater than 6 weeks, will call for fertility evaluation.
CHART NOTE
Has now developed a vesicovaginal fistula. The patient has copious amounts of urine draining from the vaginal vault.
Bimanual examination today reveals increased thickening at the apex of the vagina with significant stenosis and induration of tissue. Rectal examination again reveals a normal rectovaginal septum. The whole area of the lateral pelvic walls appears to be thickened and indurated. The anterior bladder area reveals no irregularities on palpation.
I have discussed the status with the patient and have recommended that she be seen by a gynecologic oncologist more familiar with long-term radiation effects.
CHART NOTE
This patient is a 39-year-old female who complains of severe pain in the lower abdominal area for about 24 hours at the onset of her menstrual period, and the pain is excruciating in the right lower quadrant. Lasts for anywhere from 12 to 24 hours and then disappears. Also has extensive abdominal bloating prior to and during the pain and also has episodes of constipation.
Past medical history is negative. No surgical history. Has had 3 vaginal deliveries. Had an episode of heavy vaginal bleeding in February of this year. Menstrual periods are usually 26 to 28 days apart. Used an IUD for contraception since 1976. Presently taking thyroxine.
ALLERGIES
HAS ALLERGIES TO PENICILLIN.
Vaginal ultrasound was performed. Patient is approximately
1 week prior to the onset of her menstrual period. The ultrasound shows a complex cystic ovary on the right side. Left ovary is deep into the cul-de-sac area, but is essentially normal with a small 1.5-cm follicle. The uterus is normal size. There appears to be also a small anterior fibroid.
1 week prior to the onset of her menstrual period. The ultrasound shows a complex cystic ovary on the right side. Left ovary is deep into the cul-de-sac area, but is essentially normal with a small 1.5-cm follicle. The uterus is normal size. There appears to be also a small anterior fibroid.
Pelvic examination reveals the uterus to be retroverted, mobile. Both adnexal areas reveal no masses or thickening. The right adnexal area is slightly tender. Cannot appreciate the complex cystic ovary on the left side on bimanual examination.
Have recommended that the patient await the onset of her menstrual period and then to repeat the vaginal ultrasound. If a complex cyst still is present, would then recommend pelviscopic evaluation, possible oophorectomy, possible lysis of adhesions.
FOOTNOTE
Line 8 (Page 1). Alternative: 32-40.
Line 13 (Page 1). Reveals was changed to reveal for proper subject-verb agreement.
Line 17 (Page 1). The numeral 1 was added for clarity.
Line 18 (Page 1). The correct term is oligomenorrhea, even though the physician says oligoamenorrhea.
Line 26 (Page 1). Alternative: Vesical-vaginal.
Lines 33-34 (Page 1). The awkward sentence structure was edited.
Line 47 (Page 1). The word to was added for correct grammar (prior to and during the pain).
Line 4 (Page 2). A IUD was changed to an IUD for correct grammar. It was expanded for clarification. The physician stumbles; the correct choice is since 1976.
Lines 12, 20 (Page 2). The physician said that the complex cystic ovary was present on the right side on ultrasound; in his examination, he says he cannot appreciate it on the left. The transcriptionist on the job would seek clarification from the patient’s medical chart or from the physician.
Line 18 (Page 2). The second reveals was changed to reveal for correct subject-verb agreement (both adnexal areas reveal).
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