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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 subseque=
nt
vaginal bleeding since that time. =
span>
REVIEW OF SYSTEMS:
PAST MEDICAL
HISTORY: Relevant for history=
of
hypertension and non-insulin-dependent diabetes. The patient is not more than 40=
209;50
pounds overweight.
She reports normal
mammography performed within the past 12 months.
PHYSICAL EXAMINATIO=
N: Today is limited to her abdomen and
pelvis. She declined breast e=
xam
stating she underwent evaluation of her breast with her internist. Abdomen revealed no guarding or re=
bound
tenderness. Vulvar inspection
revealed no blood or abnormal discharge.&n=
bsp;
Speculum examination identified a nulliparous cervical os. The patient has undergone no vagin=
al
childbearing though she has had two pregnancies. ThinPrep Pap smear was performed u=
sing
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.