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GYNECOLOGICAL CONSULTATION
HISTORY: This is a 53-year-old female G1, P0, postmenopa=
usal
patient, who presents today for her routine gynecological examination.
The patient has a history of an incision and drainage of BartholinR=
17;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 incis=
ed
and drained previously. She states that the area is nontender and is not la=
rge
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:
PLAN: A Pap test was performed. Disc=
ussed
the above findings with the patient. It was recommended to the patie=
nt
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 w=
ith
the management. She also will schedule for her routine mammogram. Foll=
ow
up routinely and/or p.r.n.