Audio_Gynec_Hp_27

GYNECOLOGY CONSULTATION

HISTORY:
This is a 33-year-old female G4, P3, with LMP on 03/22/06 who presents today for her routine gynecological examination and Pap test. The patient was seen here on her last visit on 01/22/06 with a complaint of bilateral breast discharge. Since that time, she has obtained a mammogram and a sonogram with the results revealing normal studies in both the mammogram and sonogram. She also had TSH and prolactin levels drawn, which are both within normal limits as well.

PHYSICAL EXAMINATION:
Breasts: No dominant masses could be appreciated. Nipple discharge only elicited by patient’s own manual expression.
Abdomen: Soft, nontender, and nondistended.
Pelvic examination: Vagina, no lesions noted. Cervix, her os is closed. Uterus is not enlarged, nontender. Adnexa, nontender, no masses are appreciated.

ASSESSMENT:
Normal gynecological examination with bilateral breast discharge.

PLAN:
A Pap test was performed. Discussed all of the above with the patient, and she was given referral to follow up with the surgeon for a complete breast evaluation and management or discharge. She also will return to this office routinely and/or p.r.n. All of her questions were answered and she agrees with the management at this time.