Audio_Gynec_Hp_26

GYNECOLOGY CONSULTATION

HISTORY: This 44-year-old G3, P3 Indian national presents today without complaints. Her stated last normal menstrual period was on April 1, 2005. Her husband accompanied her both during interview and exam phase of today’s visit.

REVIEW OF SYSTEMS: Negative for dysfunctional uterine bleeding, excessive pain or dyspareunia. She does report occasional stress urinary incontinence. She also wishes to renew her Yasmin oral contraceptive prescription. She is once again reminded of the potential for adverse vascular insults among woman of her age on the oral contraceptive pill. She accepted these risks. Options including vasectomy, condoms and permanent sterilization or IUD use were all declined.

PHYSICAL EXAMINATION: Revealed no discrete breast lesions, skin changes or nipple discharge. Blood pressure today was 116/74 mmHg. Axillae were negative. The patient was instructed on self-breast examination. Abdomen was benign. Vulvar inspection revealed no lesions. Speculum exam identified a well-supported closed parous cervical os. ThinPrep Pap smear was performed. Bimanual examination revealed no organomegaly, no cervical motion tenderness.

PLAN: The patient was issued a renewal of her Yasmin oral contraceptive pill. She was advised to immediately discontinue this medication should she develop headaches, blurred vision, leg pain or shortness of breath. The patient was encouraged to return in six months time for reevaluation, repeat blood pressures and possible renewal of her oral contraceptive. The patient was issued a referral for yearly mammogram screening.