Audio_Gynec_Hp_25

OFFICE VISIT

HISTORY: This 47-year-old multiparous black female presents today reporting a four-day episode of spotting in March 2004. She reports no subsequent vaginal bleeding since that time.

REVIEW OF SYSTEMS: Negative for hot flushes or insomnia.

PAST MEDICAL HISTORY: Relevant for history of hypertension and non-insulin-dependent diabetes. The patient is not more than 40‑50 pounds overweight.

She reports normal mammography performed within the past 12 months.

PHYSICAL EXAMINATION: Today is limited to her abdomen and pelvis. She declined breast exam stating she underwent evaluation of her breast with her internist. Abdomen revealed no guarding or rebound tenderness. Vulvar inspection revealed no blood or abnormal discharge. Speculum examination identified a nulliparous cervical os. The patient has undergone no vaginal childbearing though she has had two pregnancies. ThinPrep Pap smear was performed using cytology brush and spatula. An endometrial biopsy was performed following iodine prep and endocervical dilatation with Hanks dilators. A single pass was made introducing the Pipelle to a depth of approximately 8 cm. Minimal glandular tissue was retrieved.

PLAN: The patient was reminded to return in two weeks’ time for followup. A pelvic sonogram was also requested to evaluate the endometrial thickness and size of the uterus. She was cautioned to keep better compliance with her scheduled office appointments having failed to keep three consecutive scheduled visits since December 2005.