Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: OB/GYN Consultation - 2
Description: Consultation because of irregular periods and ovarian cyst.
(Medical Transcription Sample Report)
She is a 14-year-old G0, LMP November 25, 2006. She comes in today in consultation from ABC, nurse practitioner. She comes in because of irregular periods and cyst on her ovaries. She comes in with her mother from whom most of the history is taken.
She started her periods at age 13. She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice. She describes the pain as bilateral, intermittent, and non-radiating. It decreases slightly when she eats and increases with activity. She states the pain when it comes can last for half-a-day. It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting. She has tried LactAid, which initially helped, but then the pain returned. She has tried changing her diet and Pepcid AC. She was seen at XYZ where blood work was done. At that time, she had a normal white count and a normal H&H. She was given muscle relaxants, which did not work.
Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done. This showed a 1.9 x 1.4-cm cyst on the right with no free fluid. The left ovary and uterus appeared normal. Two days later, the pain resolved and she has not had a recurrence. She denies constipation and diarrhea. She has had some hot flashes, but has not taken her temperature.
In addition, she states that her periods have been very irregular coming between four and six weeks. They are associated with cramping which she is not happy about.
She has never had a pelvic exam. She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present. She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.
PAST MEDICAL HX: Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.
PAST SURGICAL HX: Plastic surgery on her ear after a dog bite in 1997.
MEDICATIONS: Zoloft 50 mg a day and LactAid.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HX: She enjoys cooking and scrapbooking. She does have a boyfriend; again she states she is not sexually active. She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.
FAMILY HX: Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age. She also has a paternal great grandfather who was diagnosed with colon cancer.
PE: VITALS: Height: 5 feet 5 inches. Weight: 190 lb. Blood Pressure: 120/88. GENERAL: She is well-developed, well-nourished with normal habitus and no deformities. NECK: Without thyromegaly or lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmurs. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Deferred.
A/P: Abdominal pain, unclear etiology. I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this. However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill. She has no personal or familial contraindications to start this. She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4. She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.
If she should have the recurrence of her pain, I have advised her to call.
Keywords: consult - history and phy., irregular periods, lactaid, abdominal pain, birth control pills, cyst, ovarian cyst, ovaries, ovary, pelvic exam, sexually active, uterus, lymphadenopathy, pelvic, irregular, periods,