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 is 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.
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 normal size, shape, and consistency. Adnexa clear, nontender. Rectovaginal examination confirms. Pap smear 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 is 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 confirmed.
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. Followup will be in a year.
FOOTNOTE
Line 7 (Page 1). Were was changed to was for correct
subject-verb agreement.
subject-verb agreement.
Line 20 (Page 1). The dictated comma was changed to a semicolon. Alternative: Period instead of a comma.
Lines 21, 22 (Page 1). The redundant use of currently was eliminated.
Line 18, 28, 34, 39, 43 (Page 1), 12, 15, 36, 42, 48 (Page 2). Exam was expanded in the report.
Line 22 (Page 2). The dictated comma was changed to a period.
Line 37 (Page 2). A zero was inserted before the decimal point for clarity.
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