Dear Dr. Emily Carter,
MAIN COMPLAINT:
- Patient presents with complaints of heavy menstrual bleeding and pelvic pain.
GYNECOLOGICAL:
- Menarche at age 12, regular cycles until 6 months ago, now irregular and heavy. Reports using 6-8 pads per day during menstruation. No history of sexually transmitted infections. Last Pap smear was 1 year ago, normal.
OBSTETRICAL:
- G2P2 (Gravida 2, Para 2). Two vaginal deliveries. No complications during pregnancies or deliveries.
FAMILY HISTORY:
- Mother had a history of uterine fibroids. No other significant family history.
MEDICAL HISTORY:
- No significant medical history.
MEDICATIONS:
- Ibuprofen 400mg as needed for pain.
PREVIOUS SURGERIES:
- None.
ALLERGIES:
- NKDA (No Known Drug Allergies).
SOCIAL HISTORY:
- Non-smoker, occasional alcohol use. Works as a teacher.
EXAMINATION:
- General: Patient appears in mild distress due to pain.
ABDOMINAL:
- Soft, non-tender. No masses or organomegaly.
GYNECOLOGICAL:
- Speculum exam: Cervix appears normal. Uterus is enlarged and boggy. Bimanual exam reveals a palpable, mobile mass consistent with a fibroid.
INVESTIGATIONS REVIEWED:
- None at this time.
INVESTIGATIONS ORDERED
- CBC, pelvic ultrasound.
IMPRESSION AND PLAN:
- Impression: Heavy menstrual bleeding secondary to uterine fibroids. Plan: Discussed treatment options including medical management with hormonal therapy and surgical options such as myomectomy or hysterectomy. Scheduled for pelvic ultrasound and follow-up appointment in two weeks.
DISCUSSION SURGICAL PROCEDURE:
- Discussed the risks and benefits of myomectomy and hysterectomy. Patient expressed interest in preserving fertility, so myomectomy was discussed in detail. Informed consent obtained.
Thank you for involving me in the care of the patient.
Dear [Physicians name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MAIN COMPLAINT:
- [describe main complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
GYNECOLOGICAL:
- [describe gynecological history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
OBSTETRICAL:
- [describe obstetrical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
FAMILY HISTORY:
- [describe family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MEDICAL HISTORY:
- [describe medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MEDICATIONS:
- [list medications and herbal supplements, including dose and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PREVIOUS SURGERIES:
- [list previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ALLERGIES:
- [list allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SOCIAL HISTORY:
- [describe social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
EXAMINATION:
- [describe examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ABDOMINAL:
- [describe abdominal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
GYNECOLOGICAL:
- [describe gynecological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INVESTIGATIONS REVIEWED:
- [list investigations reviewed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INVESTIGATIONS ORDERED
- [list investigations ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
IMPRESSION AND PLAN:
- [describe impression and plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
DISCUSSION SURGICAL PROCEDURE:
- [describe discussion about surgical procedure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thank you for involving me in the care of the patient.
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)
(Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)