Consult - History and Phy.
Sample Name: OB/GYN Consultation - 1
Description: Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.
(Medical Transcription Sample Report)
The patient is a 16-year-old gravida 0 female referred by Dr. A for evaluation of an abnormal colposcopy. The patient had a low-grade Pap with suspicious high-grade features. She underwent colposcopy, which showed a low-grade squamous intraepithelial lesion with a positive ECC of low-grade. The patient is very, very nervous about colposcopy and did not want to have repeat biopsies today. Based on her Pap and her ECC, we will consider LEEP. Also of note, she presented to emergency room with right lower quadrant pain x 1 week preceded by nausea, vomiting, and diarrhea and worsened over the weekend. She was seen in the emergency room and had an ultrasound and a CAT scan which were within normal limits. They ruled out appendicitis as well as an ovarian cyst. The patient is sexually active, but not currently. She denies any vaginal discharge, fever, chills, or night sweats and her pain is somewhat improved today, but still there specifically in the right lower quadrant. She denies any dysuria or blood with urination.
PAST MEDICAL HX: Significant for asthma, pneumonia, and depression.
PAST SURGICAL HX: None.
MEDICATIONS: Prozac 20 mg q.d. She desires to be on the NuvaRing.
ALLERGIES: Lactose intolerance.
PE: VITALS: Stable. Weight: 114 lb. Height: 5 feet 2 inches. GENERAL: Well-developed, well-nourished female in no apparent distress. HEENT: Within normal limits. NECK: Supple without thyromegaly. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Soft and nontender. There is no rebound or guarding. No palpable masses and no peritoneal signs. EXTREMITIES: Within normal limits. SKIN: Warm and dry. GU: External genitalia is without lesion. Vaginal is clean without discharge. Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal. BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness. She had no tenderness in her adnexa. There are no palpable masses.
A: Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease. GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg. Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A. A LEEP is a reasonable approach even in this 16-year-old.
P: We will schedule LEEP in the near future. Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions. Now, we have her given her first shot.
Keywords: consult - history and phy., gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade,