OB-GYN Study

HISTORY AND PHYSICAL EXAMINATION

This patient is a 34-year-old female, gravida 0, last menstrual period November 20.  Patient presents with a history of having been evaluated for complaints of increasing central pelvic pain, increasing vaginal discharge, and symptoms of cystitis, deep dyspareunia, sacral backache.  When evaluated, the patient was felt most likely to have a Chlamydia pelvic inflammatory disease.  She was at that time treated with 2 g of Claforan IM and given a 3-week course of Vibramycin.  She was instructed to return p.r.n. for worsening symptoms.  She returned.  States that several days after the completion of her menstrual cycle that the pelvic pain returned, particularly severe in the left side over that ovary, and she also began having problems with cystitis symptoms, i.e., frequency, hesitancy, dysuria, as well as increasing secondary dyspareunia.  Also relates history of night sweats, chills, fever elevation up to 102.

PAST MEDICAL HISTORY

Past medical history includes drug allergy to aspirin.  Current medications include Bactrim DS and Triphasil oral contraceptive pills.  The patient had 1 prior admission, at which time diagnostic laparoscopy and laser laparoscopy were performed for endometriosis.

PHYSICAL EXAMINATION

GENERAL:  On physical examination, she was a well-developed, well-nourished female in moderate distress.

EYES:  Not remarkable.

ENT:  Not remarkable.

NECK:  Not remarkable.

LUNGS:  Not remarkable.

HEART:  Not remarkable.  The CVA area was negative.

ABDOMEN:  Abdomen was soft.  No organomegaly was noted.  There was some diffuse lower abdominal tenderness to palpation, with the left being more severe than the right.

PELVIC EXAMINATION:  There was a moderate amount of yellowish, purulent-appearing leukorrhea.  The external genitalia appeared to have a mild amount of inflammation.  Bartholin and Skene glands and urethra were not really remarkable.  The cervix was
4+ tender to motion bilaterally.  The adnexal areas on bimanual examination showed the uterus to be anteverted, anteflexed, normal size, exquisitely tender to palpation.  Both adnexal areas were thickened, nodular, exquisitely tender to palpation.  Rectovaginal examination showed what was felt to be bilateral adnexal masses, 3 to 4 cm in size, with the right being more tender than the left as far as tenderness is concerned.

RECTAL:  Rectal examination also showed some thickening of the cul-de-sac of Douglas, but no nodularity of the uterosacral ligaments noted.

IMPRESSION

1. Probable pelvic inflammatory disease.  Rule out tubo-ovarian abscess.

2. History of endometriosis.  Rule out relapse of endometriosis.

FOOTNOTE

Line 13 (Page 1).  Alternative:  I.M.

Line 30 (Page 1).  Exam was expanded to Examination in the heading.

Line 31 (Page 1) - 5 (Page 2).  Subheadings were added for clarity.

Lines 42, 43 (Page 1).  The sentence was edited for clarity.

Line 1 (Page 2).  Alternative:  3-4.