Audio_Gynec_Hp_23

OFFICE VISIT

HISTORY: This 22-year-old nulligravid but sexually active Hispanic female presents today without complaints for followup. Historically, this patient had a positive Chlamydia culture documented in June 2004. She was treated successfully with Zithromax 1 g p.o. Followup culture in May 2004 revealed a negative Chlamydia and gonorrhea status. She was counseled extensively on importance of barrier contraception in terms of preventing future STDs, which could very much negatively impact her future childbearing abilities. She was reminded that a pelvic sonogram from May 2004 revealed a normal-sized uterus with an endometrium described as having “fuzzy margins” and laterally enlarged ovaries with “fuzzy margins” again. The patient had findings consistent with pelvic inflammatory disease and/or endometriosis. The patient has been issued a referral for followup pelvic sonogram.

PHYSICAL EXAMINATION: Today failed to identify any cervical motion tenderness or adnexal fullness or tenderness. Chlamydia and GC culture was once again obtained though cervix did not appear to have any abnormal discharge or erythema. Bimanual examination failed to identify any cervical motion tenderness or adnexal fullness or tenderness.

PLAN: The patient was issued a followup pelvic sonogram referral to compare contrast post treatment physical, gynecological anatomy versus the May 2004 study describing adnexal fullness and fuzzy margins of both the endometrium and adnexae.