H&P 1

CC: vaginal bleeding x6 weeks.

HPI

AL is a 43 y/o female G4P3013 with a history of abnormal uterine bleeding presenting today with vaginal bleeding. Patient underwent vaginal myomectomy 6/15/2020 for an aborting leiomyoma. Procedure was complicated by heavy vaginal bleeding 2 days later which prompted her to go to the ER and received 3UPRBC. A total vaginal hysterectomy was discussed with the patient prior as a possible treatment option. States she has had mild spotting daily since after the transfusion using 2 pads per day and takes iron three times daily. Denies any pain, passage of clots, heavy vaginal bleeding, dizziness, weakness, palpitations, shortness of breath, chest pain, fever, chills, nausea, or vomiting. Last pap and mammogram 6/2020 and both within normal limits.

PMH/PSH

Abnormal uterine bleeding 

Hysteroscopy D&C with vaginal myomectomy 6/15/2020

OBhx: NSVDx3, SAB x1

GYNhx: Menarche age 12. menses are regular, monthly lasting 5 days. Denies history of fibroid uterus, STI, PID, chronic pelvic pain, abnormal pap or GYN malignancies

Transfusion s/p vaginal myomectomy June 2020

Medications

Iron 65mg tab PO TID

Allergies

NKDA

ROS

General – denies fever, chills, weakness, change in weight 

Respiratory – denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea

Cardiovascular –  denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Breast – Denies lumps, nipple discharge, or pain.

GI– Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

GU – admits to abnormal vaginal bleeding. Denies abnormal vaginal discharge, dyspareunia, abdominal/pelvic pain, dysuria, hesitancy, urgency, incontinence, change in bowel habits, or rectal bleeding.

PE

Vital Signs – BP 110/68, P 78, RR 16, Temp 98.6, O2 99% on room air, BMI 30

General – AOx3, in NAD, appears well nourished and well dressed. Appears stated age of 43.

Breasts -symmetric, no dimpling, no masses, nipples without discharge.  No axillary nodes palpable 

Lungs – Clear to auscultation bilaterally, no wheezes, rales, or rhonchi

Heart – RRR, S1 S2, no rubs, murmurs or gallops

Abdomen – soft, non tender non distended

Pelvic Exam 

Lymph nodes- No inguinal adenopathy

vulva – no lesions, masses, bruising, or white mucopurulent d/c from introitus 

urethral orifice – normal, no erythema or discharge

vaginal mucosa- pink, moist, minimal blood in vault 

cervix – Os slightly open 1-2 cm, multiparous, pink, no discharge or erythema, no CMT

uterus- midline, anteflexed, smooth, nontender, w/o enlargement,

Adnexa – w/o tenderness or masses, ovaries nonpalpable

Assessment/ Plan

43y/o female s/p vaginal myomectomy for aborting myoma 6/15/20 presenting today with continued mild vaginal bleeding.

1. Abnormal uterine bleeding

Discussed treatment plan of total vaginal hysterectomy prior to today’s admission. Patient has opted for surgery. 

CBC, CMP, T&S

IV fluids, NPO

 

H&P 2

CC: routine GYN exam and frequent, heavy periods x2 months

HPI

40 y/o female G2P1001 here for routine GYN exam and frequent, heavy periods x2 months. As per patient, she had regular monthly periods lasting 7 days from 12/2019 to 5/2020. In June she had a period that lasted for 2 weeks (6/20-7/3), and then again from 7/11-7/25. She states her menses were heavier than usual, but denies any passage of blood clots. Had Nexplanon placed in 2019 for contraception and is sexually active with a male. Denies dysmenorrhea, dyspareunia, vaginal discharge, abdominal pain, fever, chills, lightheadedness or weakness. She denies dysuria or any urinary complaints but admits to intermittent pruritus on the right labia for x3 weeks. Admits to abnormal pap smear and HPV in 2/2017. Denies any other sexually transmitted infections. Last pap smear in 2018 was normal. Last mammogram in 2019 was normal.

PMH

OBhx: NSVDx1, SABx1 

GYNhx: Menarche age 14. Menses were regular and monthly from December 2019 to June 2020, lasting 7 days. Periods in June and July were lasting 2 weeks long and had a short interval between periods, lasting 1.5 weeks. 

Nexplanon in April 2019 

Abnormal Pap smear in February 2017 (ASCUS, HPV+, ECC negative)

Last Pap smear in August 2018 was normal and HPV negative 

Denies any other STIs, fibroids, or cancer

Last mammogram 2019 normal

Medications 

none   

Allergies 

NKDA

ROS

General – denies fever, chills, weakness, fatigue, change in weight 

Respiratory – denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea

Cardiovascular –  denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Breast – Denies lumps, nipple discharge, or pain.

GI– Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

GU – Admits to heavier menses with short intervals between cycles. Admits to pruritis in the right labial area. Denies abnormal vaginal discharge, dyspareunia, abdominal/pelvic pain, dysuria, hesitancy, urgency, incontinence, change in bowel habits, or rectal bleeding.

PE

Vital Signs – BP 107/73, P 80, Temp 98.2, BMI 30.99

General – AOx3, in NAD 

Breasts – Breasts symmetric, no dimpling, masses, nipples without discharge. No axillary nodes palpable 

Abdomen – soft, non tender non distended

Pelvic Exam: 

Lymph nodes- No inguinal adenopathy

vulva – hypopigmented area on right labia minora. no erythema, lesions, masses, bruising

urethral orifice – normal, no erythema or discharge

vaginal mucosa- moist, no erythema or abnormal discharge

cervix – Os closed, multiparous, pink, no discharge or erythema, no CMT

uterus- midline, anteverted, smooth, nontender, w/o enlargement

Adnexa – w/o tenderness or masses, ovaries nonpalpable

Assessment

40 y/o female G2P1001 here for routine GYN exam and frequent, heavy periods x2 months and right labial pruritis.

• Routine GYN exam 
• Polymenorrhea
• Menorrhagia 
• Lichen sclerosus (?) 

Plan

• F/u in 2 weeks for possible EMB for abnormal uterine bleeding
• If hypopigmented area still present on labia, will consider for possible biopsy to r/o malignancy, lichen sclerosus