Audio_Gynec_Hp_28

GYNECOLOGICAL CONSULTATION

HISTORY: This is a 53-year-old female G1, P0, postmenopausal patient, who presents today for her routine gynecological examination. The patient has a history of an incision and drainage of Bartholin’s cyst approximately one year ago. At this time, she states over the last few weeks she has noticed a “bump” in that same area that was incised and drained previously. She states that the area is nontender and is not large in size. She has no other symptoms.

PHYSICAL EXAMINATION:
Breasts: No masses are appreciated.
Abdomen: Soft, nontender, and nondistended.
Pelvic examination: Vagina: A very small non-fluctuant masses noted in the lower right labial area. No lesions noted. Cervix: Her os is closed. Uterus: Not enlarged and nontender. Adnexa: Nontender. No masses are appreciated.

ASSESSMENT: Normal gynecological examination with an extremely small non-fluctuant mass, most likely representing a Bartholin gland cyst.

PLAN: A Pap test was performed. Discussed the above findings with the patient. It was recommended to the patient to continue to observe the site and performed sitz baths three times a day. She was also given a prescription for Keflex 500 mg p.o. q.i.d. for seven days and also she will return to the office should she notice any enlargement of the area and/or tenderness. All of her questions were answered and she agrees with the management. She also will schedule for her routine mammogram. Follow up routinely and/or p.r.n.