Mon 2/17
0717
0715
Wyatt
TAH - BSO
Doe,Jane MRN####
BMI 31
Kg: 106
48 yof G0P0 with fibroid uterus and h/o anemia. In past, Dr. Gleason recommended Hyst but pt
declined. EMB 11/2012 was negative. Currently on Alesse. Reports worsening irregularity of her
bleeding despite the OCPs. She is having more pelvic discomfort, she wishes to proceed with
hysterectomy.
PMH: HTN PSH: Myomectomy –‘02 All: NKDA Meds: hctz-lisinopril 12.5/10, OCP Imaging: uterus
measuring 13.3 x 9.6 x 9.7cm with multiple subserosal myomas present. Path: Pap-NIML, EMB
normal- 11/2012. Labs: Hct 37 Last appt: 2/5/14
[ ] preop
[ ] depart/dc
[ ] dictate
0717
1030
Wyatt
HSCEndometrial
Ablation
Doe, Sarah MRN####
[ ] preop
[ ] depart/dc
[ ] dictate
BMI: 44.5
Kg: 114
33yo P2002 with history of AUB. EMB on 2/5 – normal. Has opted to proceed with HSC/EA.
PMH:PCOS, h/o PTE (2013), HTN, Depression PSH: C/S x 2, BTL, ex Lap (8/2012) All: NKDA
Meds: atenolol 50, HCTZ-Lisinopril 12.5/10, Lexparo Imaging: TVUS5/3: UT- 8.7x4.1x3.6. Prominent
endometrium. Ovaries WNL Path: EMB- Normal Labs: None Last Appt: 2/5/14
0717
1430
Wyatt
Tue 2/18
Wed 2/19
Thu 2/20
Fri 2/21
Lsc BTL,
HSC, D&C,
endometrial
ablation
Doe, Laura MRN####
BMI 27 Kg: 87
35 yo WF P 2002 with AUB. Heavy bleeding over last 4 months occurring every 1-2 weeks lasting for up
to 19 days. Pt reports significant migraines in past with use of OCPs. Pt desires definitive surgical
management.
PMH: Bi Polar Disorder, GAD, Hep C, PTSD, MVP PSH: c/s x 2, Facial reconstruction All: Mayonaise
Meds:Celexa 20, Mobic, Robaxin, Tramadol 50 Imaging: TVUS 2/11: 1. Heterogeneous cystic and solid
left ovarian mass with vascular flow is worrisome for neoplasm, but possibly may represent sequela of
prior PID. Measures: 7.1 x 4.7 x 4.4 cm 2. Left hydrosalpinx is larger than on previous CT.3. Mildly
enlarged heterogeneous uterus may represent adenomyosis or diffuse myomatous change. UT- 9.0 x 5.5
x 6.1 Path: None Labs: Hct 34 Last Appt: 2/10/14
[ ] preop
[ ] depart/dc
[ ] dictate