11/14/____  JANE DOE                         #00-00-00-0

(Copy to John Doe, M.D.)

Jane is seen in consultation from Dr. Dolittle regarding prolapse.  The patient is a 78-year-old, white female, G4, P3, AB1, whose last menstrual period was in her late fifties. 

She reports having problems for years with a feeling that there is some tissue protrusion, and it started when she moved some furniture.  Her big problem, however, is urine loss; and it requires that she wear protection night and day.  Most of the urine loss occurs with urgency.  She states when she gets up to go to the bathroom at night, she cannot get to the bathroom in time and will lose urine on the way.  That is why she has to wear protection at night.  She normally gets up three to four times a night. 

The patient has been evaluated for this problem before, and at one time was scheduled to have a vaginal hysterectomy and repair but broke her leg and did not go through with the surgery at that time.  She also states she was given estrogen once which she used for a year but did not feel it was helping and therefore did not continue. 

The patient has been seen in urology here by Dr. Jones and had cystoscopy done and was offered collagen injections which she had.  She stated that they benefited for a short time. 

Review of the patient's chart also indicates consultation with cardiology for apparent angina and heart disease.

The patient does have apparent problems with mobility as she was here using a cane and at home apparently uses a walker.  She has some problems with forgetfulness and brought two daughters with her today to help her understand the recommendations.  They indicated that she has previously had a urology evaluation in Des Moines where they were advised that the cystocele was not a factor in the problem, but they did not seem very clear on what was recommended to help it. 

PHYSICAL EXAMINATION:  The patient is a thin, elderly woman who is well oriented and cooperative.  Vital signs are as noted above. The abdomen is soft and flat with no palpable lower abdominal masses.  On pelvic exam, the external genitalia show no relaxation at rest but with straining there is a small cystocele that does prolapse a little.  The vagina is atrophic with no visible lesions.  The cervix is atrophic with no lesions and prolapses very minimally with straining.  On bimanual exam, the fundus is quite small; and there are no palpable adnexal masses.  Rectal exam confirms.

ASSESSMENT:  Although the patient complains of a cystocele, her overriding problem today appears to be urinary incontinence.  The incontinence appears to have mixed etiology, and the patient also seems to be affected by mobility impairment and forgetfulness. 

PLAN:  Advised patient that we start with institution of a vaginal estrogen cream one-half applicator q. h.s. for seven days  followed by reduction in dose to twice a week.  Advised to keep a bladder diary for two days and to return in two weeks for further management. 

Discussed the complex causes or urine loss with the patient and her daughters and the possibility of trying a pessary for her problem to see how much benefit this would have prior to further recommendations.  Advised I did not expect a cystocele repair to have any significant benefit for her symptoms and would expect with the use of some vaginal estrogen that she will be minimally symptomatic from the prolapse at this time.  Forty minutes spent with the patient and family with over 50 percent in counseling. 

Jan Doe,M.D./ht:___

09/09/____  JENNY DOE                          #00-00-00-00

Jenny is seen for an annual exam.  She reports no problems with her menstrual cycles but is not planning to have another child and continues to use contraception.  She has noted an increase in problems with irritability and moodiness the week prior to menses. 

PHYSICAL EXAMINATION:  Vital signs are as recorded.  General appearance - normally developed, well-groomed female.  Neurologic - Patient is alert and oriented times three.  Neck - without thyromegaly or masses.  Lungs - clear to auscultation. Heart - regular rate and rhythm without any murmurs.  Abdomen - without any masses or tenderness.  There is no hepatosplenomegaly or hernias present.  Breasts - without any masses, discharge, or axillary nodes.  External genitalia - normal female without any lesions.  BUS - negative for any lesions. Vagina - without any lesions, well supported.  Cervix - without any lesions, no cervical motion tenderness.  Uterus - anterior, normal size, mobile, and nontender.  Adnexa - without masses or tenderness.  Rectovaginal - normal-appearing anus and perineum, normal sphincter tone, no nodularity noted.  Lymphatic - no lymphadenopathy noted.  Skin - There are no rashes or lesions noted. 

ASSESSMENT:  Normal exam.

PLAN:  Discussed measures related to diet and exercise that may decrease symptoms of premenstrual tension and given a pamphlet on premenstrual syndrome from ACOG.  Advised a supplemental vitamin. 

Discussed preventive screening, and the patient will be due for lab work next year along with starting screening mammograms.  Jan Doe, M.D./ht:___

12/10/____  JANE DOE                                             #2-74-87-8

Jane is seen for an annual exam.  She reports that on the Depo Provera she sometimes does get spotting at the end of the three months when the shot is due.  She has no regular menses and no heavy bleeding.  She gets no hot flashes or menopausal symptoms. 

The patient continues to get checkups with Dr. Lowry approximately every three months related to her cholesterol.  She states she is trying to follow an exercise program and a low-fat diet. 

PHYSICAL EXAMINATION:  Breasts - no masses; no axillary masses. Abdomen - no masses; no organomegaly.  Pelvic exam - external genitalia are normal.  The cervix has no lesions.  The fundus is enlarged and irregular, approximately a 12-week size with no separate adnexal masses appreciated.  Rectal exam confirms.

ASSESSMENT:  1)  Uterine leiomyomata with little change in size from her last visit.  2)  Little problem with bleeding on Depo Provera injections.   

PLAN:  Continue Depo Provera and discussed monitoring for menopause starting at approximately age 50.  Encouraged to follow through on increasing her exercise program and following a low-fat diet.  Jan Doe, M.D./ht:___

12/03/____  JEN DOE                          

#00-00-00-0

Jen is a 55-year-old, white female, G3, P3 seen in consultation from Dr. Jones for a recurrent Bartholin abscess. 

The patient reports that she had a recurrence of perineal pain and swelling followed by spontaneous drainage a week ago and was seen and started on antibiotics.  Her symptoms have pretty much resolved at this time.  However, this was the third occurrence of this in the past year. 

The patient was noted to be on hormone replacement therapy and indicates she thinks she stopped her menses at about the age of 35.  However, her old records show that she was still menstruating at age 39 when she had tubal sterilization.  She did apparently stop at that time because at the age of 40, she was started on hormone replacement therapy based on the fact that her twin sister had been also diagnosed as being menopausal.  She has been on hormone replacement with cyclic progestin ever since then.  She states she does not drink milk but is using a calcium supplement.  She also had a screening bone density done in a drug store on her wrist that showed her below average but normal.

PHYSICAL EXAMINATION:  Examination of the external genitalia did not show any abnormalities, although an old retracted scar was noted on the left side of the perineum.  There was specifically no tenderness or swelling in the area of either Bartholin gland and no evidence of the site of drainage.  A vaginal exam shows no abnormalities.  The cervix has a very small endocervical polyp and no other lesions.  On bimanual exam, the fundus is small, anteflexed, and mobile.  There are no palpable adnexal masses. Rectal exam confirms. 

ASSESSMENT:  1)  Description of recurrent pain, swelling, and drainage in the Bartholin area which cannot be confirmed on exam today since the symptoms seem to have completely resolved.  2)  History of early menopause at the age of 40 with hormone replacement therapy started at the age of 44 and used since then. 

PLAN:  The patient was advised if she has a flare up symptoms of infection on the perineum that she be seen at that time to verify the site of the problem and give better advice about management. 

Discussed her having a bone mineral density due to her history of early menopause at approximately age 40.  Advised patient that she could be using a continuous estrogen/progestin regimen at this point and eliminate having withdrawal bleeding.  She was given a prescription for Prempro 2.5 mg to use once daily.  Forty minutes spent with patient with over 50 percent in counseling. 

Jan Doe, M.D./ht:___

12/05/____  JENNY DOE                      #00-02-00-0

(Copy to Dr. Jones)

Jenny is seen for a colposcopic exam for a recent abnormal Pap smear showing "possible high-grade dysplasia".  The patient is a 47-year-old, white female, G0, who reports her last menses to be January 1999.  She denies any previous abnormal Pap smears. She is not a smoker and denies any history of sexually transmitted diseases.  She is married for 18 years, but her husband had a vasectomy prior to their marriage as he had a previous marriage and family. 

The patient's menstrual history is peculiar in that she had treatment for a breast carcinoma including radiation and chemotherapy in 1991 and subsequently apparently had no menses for a number of years.  She states that she resumed having menses at a yearly interval since then, and they have been "typical menses".  She has not had any evaluation of this despite her history of tamoxifen therapy. 

PHYSICAL EXAMINATION:  Visualization of the cervix shows atrophic changes, and a squamocolumnar junction is not visible.  Application of 3% acetic acid does not result in the visualization of any abnormal epithelium, and the epithelium is again noted to be very thin.  An endocervical curettage was performed. 

ASSESSMENT:  1)  Colposcopy inadequate for evaluation of abnormal Pap smear, and endocervical curettage pending.  

2)  History of recurrent postmenopausal bleeding in patient with past history of tamoxifen therapy.  This raises question whether the abnormal Pap smear is due to other pelvic pathology than cervical. 

PLAN:  The patient was advised to schedule a vaginal ultrasound to assess for endometrial of ovarian disease as a source of the abnormal cells on her Pap smear.  We will discuss today's biopsy further and follow up at that time.

Jan Doe, M.D./ht:___

11/20/____  NORMA DOE                     #00-00-70-0