CHIEF COMPLAINT: Uterine fibroids.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gravida 0, who presents today with irregular heavy menstrual cycle. The patient reports for the last two to three months, she has noted heavy bleeding that persisted for more than seven days. The patient speaks only Spanish and is accompanied today with an interpreter. The patient any weight loss or weight gain. The patient has occasional vaginal discharge. No frequency, urgency or dysuria. The patient reports no fever or chills.
PAST MEDICAL HISTORY: Significant for history of left ear tympanic perforation. History is also significant for ulcer.
PAST SURGICAL HISTORY: Unremarkable.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She denies smoking or illicit drug use.
REVIEW OF SYSTEMS: Otherwise negative. See attached medical history questionnaire.
FAMILY HISTORY: Unremarkable for breast, ovarian, or endometrial cancer. Father with lung cancer.
PHYSICAL EXAMINATION: Today, the patient’s height is 5 feet 0 inches, weight is 108 pounds, blood pressure is 100/62. In general, the patient is a well-appearing female in no apparent distress. She is alert and oriented x3. Her neck is supple with no lymphadenopathy. Chest: Adequate inspiration. Abdomen: Soft, nontender. No rebound or guarding. Pelvic Exam: Normal appearing external genitalia. The uterus is approximately 10 weeks’ size, irregular shape, consistent with uterine fibroids and no cervical motion tenderness. No adnexal masses.
IMPRESSION AND PLAN: The patient is a (XX)-year-old gravida 0, who presents today with symptomatic uterine fibroids. Pelvic ultrasound done two months ago showed a fibroid uterus, largest fibroid measuring 4.2 x 4.2 x 4 cm. Multiple fibroids are seen. Left ovary is normal and the right ovary is normal. We had a long discussion today with the patient about her abnormal uterine bleeding with the aid of the interpreter. We discussed that an endometrial biopsy is indicated in order to rule out endometrial hyperplasia or malignancy. She understands. The patient declines a biopsy at this time, and she would like to think about her options. She will follow with us in two weeks.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old para 1, Hispanic female who presents for postoperative check. Three weeks ago, she had an urgent laparoscopic-assisted vaginal hysterectomy performed for pelvic pain, dysfunctional bleeding, fibroids, and adenomyosis. Operative findings showed uterine fibroids, adhesions of the sigmoid colon to the uterine fundus, and minimal endometriosis in the posterior cul-de-sac. The tubes and ovaries were normal and were left in place. Filmy adhesions from the cecum and sigmoid colon to the anterior peritoneum were left in place. The patient reported constipation initially after the surgery, but this resolved with stool softeners and laxatives. She denies nausea, vomiting, or constipation currently. She has no fever. Her appetite is not completely normal. She denies vaginal bleeding or urinary symptoms. She has some yellow vaginal discharge.
PAST MEDICAL, SOCIAL, AND FAMILY HISTORY: No change since her admission history and physical.
CURRENT MEDICATIONS: P.r.n. Midrin for migraines.
ALLERGIES: Ibuprofen and Augmentin.
PHYSICAL EXAMINATION: Height is 5 feet 10 inches, weight 140, down roughly 10 pounds since prior to the surgery. Blood pressure 112/72. Pain score is 2-3. There is drooping of the left eyelid as before, which the patient attributes to migraine headache. The abdomen is flat and soft. Laparoscopic incisions are healing well without erythema, discharge, or tenderness. The patient reports periumbilical and right lower quadrant pain. There is mild tenderness in the right lower quadrant, but no rebound. External genitalia exam is normal. Speculum exam shows normal vaginal mucosa. The vaginal apex is healing well and suture material is still present. Bimanual examination shows no lesions in the vestibule, bladder, or urethra. Vaginal apex is smooth. There is suggestion of fullness at the vaginal apex with moderate tenderness suggestive of possible hematoma. The adnexa are not palpable.
ASSESSMENT: The patient is a (XX)-year-old para 1, Hispanic female with continuing pelvic pain and pelvic tenderness on examination three weeks after laparoscopic-assisted vaginal hysterectomy and lysis of bowel adhesions. Pathology report was benign showing fibroids and proliferative endometrium.
PLAN: We have advised a course of antibiotics and a prescription for Cipro 250 mg t.i.d. was provided for 10 days. Followup with us in two weeks is advised. The patient is cleared to return to work part-time next week. She was advised to avoid intercourse and tampons until cleared by us. Follow up with her primary care physician regarding migraine headaches, amenorrhea, anorexia, and weight loss is advised.
