Pelvic Note - Lock Haven University

Pelvic Note
Elijah Hanna PA-S
Lock Haven University PA Program
Name: ****** *****
MRN: ########
Race & Gender: Hispanic Female
Insurance: Blue Cross Blue Shield
D.O.B.: 11/11/1961
Date: 1/28/13
CC: Annual Gynecological and Breast Exam
HPI: Mrs. ***** is a 51-year-old, G2P2 female that presents to the clinic for a well
woman check including a manual breast exam, pelvic exam and PAP smear. The
patient is a Spanish speaking only woman that requests the use of a translator
through the phone. Claims to be in good health and her LMP was 1/10/13 which
was consistent with her usual 5 day duration and moderate discharge requiring 3-4
tampons per day. Patient’s only complaint is intermittent, intravaginal dryness that
leads to some mild discomfort during intercourse. This has been occurring over the
last 3 months and she denies any worsening of the symptoms. Patient has used
lubrication, which provided relief during intercourse. Patient denies any vaginal
pain without intercourse. Patient denies any dysuria, hematuria, urinary frequency
or urgency, feeling of mass or pressure in pelvic area, pelvic pain, vaginal discharge
or bleeding, post-coital bleeding, cramping, spotting, vaginal itching, or any inner or
outer pelvic lesions. Patient denies any history of or current breast masses,
tenderness, skin changes, nipple discharge, changes in breast size or self-breast
exams. Patient denies any fatigue, fever, dizziness or lightheadedness, headaches,
hot flashes, heat/cold intolerance, cough, shortness of breath, chest pain,
palpatations, abdominal pain, nausea, vomiting, diarrhea/constipation,
hematochezia or melena. Patient denies any history of sexually transmitted
diseases, breast or pelvic diagnoses, or labor complications. Claims to be in a happy,
monogamous relationship with her husband with weekly sexual interaction. Last
gynecological and breast exam was 1/9/12.
PMH: Chronic hypertension which is well controlled with medication. Denies
congenital diseases, anemia, osteoporosis, CVA, DM, CAD, clotting or bleeding
disorders, pulmonary diseases, gastrointestinal diseases, renal diseases, or cancer.
OB/GYN: Patient is premenopausal with monthly menstrual periods as noted in
HPI. LNMP 1/10/13, first menses at age 13. G2P2, vaginal deliveries in 1984 and
1987 with no complications. No abnormal PAP smears.
Immunizations: Up to date. Gets a yearly influenza vaccine. Denied Gardasil vaccine
at last well woman check up.
Surgeries: ORIF of fractured ankle in 2009. Appendectomy in 1970’s.
Hospitalizations: For appendectomy in 1970’s.
Medications: HCTZ 25 mg PO, ASA 81 mg PO, Centrum’s Women’s Health
Allergies: NKDA. Environmental including Ragweed.
Family History:
Father, Alive at 72-years-old, Hx. of DM type 2 and HTN
Mother, Alive at 70-years-old, Hx. of Asthma, HTN, CAD
Brother, Alive and well at 54-years-old
Sister, Alive and well at 49-years-old
Daughter, Alive and well at 28-years-old
Son, Alive and well at 25-years-old
Social History: Patient is in a happy, monogamous relationship with her husband of
28 years. They have two children that live locally outside their home. Regular,
weekly oral and vaginal sexual interaction. Denies any anal intercourse. She works
alongside her husband at their local restaurant. Has family and friends in the area
providing a strong support group. Patient denies any history of or current alcohol,
tobacco, or illicit drug use. She enjoys running her restaurant and watching her
Physical Exam:
General: Patient is A&O x’s 3. No acute distress. Appears as stated age. Dressed
appropriately with no indication of poor hygiene. Spanish speaking only.
Vitals: BP-126/84, HR-72, Temperature-98.8 F, Weight- 144 lbs., Height-5’7”
Chest/Lungs: No scars, lesions, masses or labored breathing. Symmetrical
diaphragmatic excursion and no dullness to percussion. Chest and back are nontender to palpation. Breath sounds clear to auscultation with no wheezes, ronchi,
crackles or rales.
Cardiac: Visible PMI at the left mid-clavicular line and 5th intercostal space. No
palpable thrills. Regular rate and rhythm with normal S1 and S2. No murmurs,
clicks, rubs, or gallops.
Breast: Symmetrical in size and shape. No visible masses, nipple retraction,
erythema, inflammation, dimpling, nodularity, thick/dry skin, or peau d’ orange.
Non-tender to palpation with no palpable masses or induced nipple discharge
bilaterally. No palpable axillary lymphadenopathy bilaterally. Examined in the
sitting in supine positions.
Abdominal: No visible scars, lesions, masses, or abnormal pulsations. No abdominal
aorta, renal, external iliac, or femoral bruits to auscultation. Bowel sounds heard in
all four quadrants at equal intensity. Percussion reveals no hepatosplenomegaly or
bladder distension. Non-tender to light or deep palpation with no masses or
Pelvic: External genitalia reveals Tanner stage 5 hair distribution. Vulva, labia and
perineum without lesions, erythema, ulcerations, masses or tenderness to palpation.
Speculum exam reveals pale pink, and slightly dry vaginal mucosa with no
discharge, odor, lesions, masses, erythema or inflammation. Parous cervical os
noted with no visible lesions, masses, or discharge noted. Cervix is freely mobile
with no cervical motion tenderness. Brush and spatula specimens taken. Bimanual
exam reveals anteverted, mobile and firm uterus with no masses, lesions, or
tenderness. Adnexa was non-palpable and non-tender bilaterally. Rectovaginal
exam reveals no masses or tenderness with appropriate sphincter tone and no fecal
occult blood.
Assessment: Healthy, premenopausal, G2P2 51-year-old female with new onset
atrophic vaginitis and chronic hypertension. New atrophic vaginitis could suggest
pending menopause.
Pending Labs: PAP smear specimens sent to cytology for analysis. Mammogram
ordered for 2/5/13.
Referrals/Consults: None
Treatment: Suggested OTC Water-Soluble Vaginal Lubricant. Apply as suggested
prior to vaginal penetration.
Patient Education: Patient educated on atrophic vaginitis and encouraged to use
water-soluble vaginal lubrication prior to sex. Advised to not use any non-watersoluble lubricants due to increase in infection rates and insult to sexual
prophylactics like condoms or diaphragms. Advised to avoid scented soaps, lotions,
perfumes or douches. Educated on correlation with menopause and decreased
estrogen levels. Progressive pain, unrelieved symptoms, or new symptoms warrants
acute follow up and reevaluation. Told there was more aggressive treatment option
such as Premarin Vaginal Cream that may be an option if this treatment option fails.
Patient agreed with treatment plan and had no questions or concerns. Patient will
receive a letter in the mail with her PAP smear results. We will call if there are any
abnormal results.
Follow Up: Return to care in 1 year for repeat gynecological and breast exam.
Follow up before as needed.
Elijah Hanna PA-S (1/28/13)