Patient is here for routine examination. Complains of increasing hot flashes and night sweats. Has only right ovary present.
Breast examination revealed no masses or tenderness. Abdomen is negative. Right pelvic area is totally normal. Vaginal cuff is negative. Cul-de-sac is free. Pap smear done. No vaginitis.
Will obtain an FSH and estradiol to possibly consider estrogen replacement therapy. Will call in several days for results of tests.
CHART NOTE
IUD inserted without difficulty. Uterine cavity sounded to a depth of 7.5 cm, smooth and regular. String trimmed. Has some mild bleeding from tenaculum site; otherwise, procedure was performed without complication. Will return to office in
6 months for IUD check. Advised that first menstrual cycle may not have full protection against pregnancy.
6 months for IUD check. Advised that first menstrual cycle may not have full protection against pregnancy.
FOOTNOTE
Lines 21-22. The redundant phrase IUD inserted without difficulty was deleted (the physician already dictated the same phrase on line 21).
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