Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: OB/GYN Consultation - 3
Description: Consultation for an ASCUS Pap smear.
(Medical Transcription Sample Report)
The patient is a 40-year-old G2, P2, LMP December 06, 2006. She comes in today in consultation from Dr. A for an ASCUS Pap smear.
Pap smear in November 2006 showed atypical squamous cells of undetermined significance. She has a history of an abnormal Pap smear. At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia. She underwent a cone biopsy that per her report was negative for any pathology. She had no vulvar treatment at that time. Since that time, she has had normal Pap smears. She denies abnormal vaginal bleeding, discharge, or pain. She uses Yaz for birth control. She reports one sexual partner since 1994 and she is a nonsmoker.
She states that she has a tendency to have yeast infections and bacterial vaginosis. She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections. She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr. B. She also has a history of chlamydia when she was in college.
PAST MEDICAL HX: Depression.
PAST SURGICAL HX: None.
MEDICATIONS: Lexapro 10 mg a day and Yaz.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
OB HX: Normal spontaneous vaginal delivery at term in 2001 and 2004, Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces.
FAMILY HX: Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use. He currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.
SOCIAL HX: She is a public relations consultant. She is a nonsmoker, drinks infrequent alcohol and does not use drugs. She enjoys horseback riding and teaches jumping.
PE: VITALS: Height: 5 feet 6 inches. Weight: 139 lb. BMI: 22.4. Blood Pressure: 102/58. GENERAL: She is well-developed and well-nourished with normal habitus and no deformities. She is alert and oriented to time, place, and person and her mood and affect is normal. NECK: Without thyromegaly or lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmurs. BREASTS: Deferred. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Normal external female genitalia. Vulva, vagina, and urethra, within normal limits. Cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance. GC and chlamydia cultures as well as a repeat Pap smear were done.
Colposcopy is then performed without and with acetic acid. This shows an entirely normal transformation zone, so no biopsies are taken. An endocervical curettage is then performed with Cytobrush and curette and sent to pathology. Colposcopy of the vulva is then performed again with acetic acid. There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter. There are absolutely no abnormal vessels within this area. The vulvar colposcopy is completely within normal limits.
A/P: ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup.
We will check the results of the Pap smear, in addition we have ordered DNA testing for high-risk HPV. We will check the results of the ECC. She will return in two weeks for test results. If these are normal, she will need two normal Pap smears six months apart, and I think followup colposcopy for the vulvar changes.
Keywords: consult - history and phy., lmp, ascus, pap smear, abnormal pap smear, atypical, bacterial vaginosis, chlamydia, cone biopsy, infection, interstitial cystitis, intraepithelial, mammogram, neoplasia, perirectal condyloma, squamous, vaginal bleeding, vulvar, yeast infection, pap smears, pap, ob/gyn, colposcopy, smear,