HISTORY AND PHYSICAL EXAMINATION
This 46-year-old female has been followed routinely. Over the past 2 years she has noted increasing menometrorrhagia. A D&C showed continued fundal enlargement with submucous fibromyomata found at the time of the D&C. Because of the heavy bleeding which has repeatedly decreased the hematocrit to the 26 to 28% range, and which interferes with the quality of life and ability to work, patient has requested TAH, which will be carried out at this time.
MENSTRUAL HISTORY
Normal menarche, cycles now 25-28 x10 with large clots and heavy flow along with usual cramping. The patient is a para 3,
2-0-1-2, Rh negative, unsensitized. She has not responded to the use of progesterones to decrease the above-noted menses, and thyroid functions had been within normal limits. There is no history of bleeding or clotting deficiencies, and patient has been followed routinely by her internist because of the history of a previous heart murmur and the repeated findings of anemia.
2-0-1-2, Rh negative, unsensitized. She has not responded to the use of progesterones to decrease the above-noted menses, and thyroid functions had been within normal limits. There is no history of bleeding or clotting deficiencies, and patient has been followed routinely by her internist because of the history of a previous heart murmur and the repeated findings of anemia.
FAMILY HISTORY
Paternal family history of high blood pressure.
PAST MEDICAL HISTORY
An excision of pilonidal sinus. I&D of left breast abscess. D&C for incomplete abortion. Bilateral Pomeroy with appendectomy. D&C for menometrorrhagia. Has a history of congenital heart murmur.
PHYSICAL EXAMINATION
GENERAL: Well-developed, well-nourished female in no distress.
NECK: Thyroid is smooth.
BREASTS: Nipples are everted, no abnormal masses are palpable.
CHEST: Clear to auscultation and percussion.
HEART: Normal sinus rhythm, with a harsh systolic blow at the pulmonic area and along the left sternal border. No cardiac enlargement is percussed. Blood pressure 150/80 in the right arm, sitting. Leg pulses are normal.
BACK: No CVA or spinal tenderness.
ABDOMEN: Liver, spleen, and kidneys are not remarkable.
PELVIC EXAMINATION: External genitalia reveal normal female, B, S, and U negative. The vagina is well-epithelialized with good support. The cervix is multiparous and in normal position. On bimanual examination, the fundus is midanterior, approximately
10 weeks’ gestational size, rounded, globular, and irregular in outline. The adnexa are normal as palpated. Pap smear class 2.
10 weeks’ gestational size, rounded, globular, and irregular in outline. The adnexa are normal as palpated. Pap smear class 2.
RECTAL: Rectal examination confirms the above.
IMPRESSION
Menometrorrhagia secondary to fibromyomata.
DISPOSITION
For TAH with ovarian preservation if possible.
FOOTNOTE
Line 36 (Page 1). General was added.
Line 43 (Page 1). Legs pulses was changed to leg pulses.
Line 45 (Page 1). Kidney was changed to kidneys.
Lines 46, 47 (Page 1). B, S, and U refers to Bartholin’s, Skene’s, and urethral glands, more often called BUS (Bartholin’s urethral, and Skene’s).
Line 48 (Page 1). The slang term multip was changed to multiparous.
Line 2 (Page 2). Pap smear class 2 was moved from Rectal to Pelvic.
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