Female Reproductive System

Use the words below to fill in the medical report:

• Transvaginal
• Laparoscopy
• Dysmenorrhea
• Pain
• Endometrial
• Tissue
• Cysts
• Pelvic
• Endometriosis

FEMALE REPRODUCTIVE SYSTEM – MEDICAL REPORT

PATIENT NAME: Stacey ROBERTS
AGE: 28 Sex: Female
DOB: October 27
DATE OF ASSESSMENT: July 22
ADMITTING PHYSICIAN: Adam Vance, MD, Gynecology

DIAGNOSIS: Endometriosis

HISTORY: This 28-year-old white female came to me with symptoms of _____ [Blank 1]. She presented with _____[Blank 2], menorrhagia, and pain with intercourse.

PHYSICAL EXAMINATION: During a _____[Blank 3] exam, abnormalities were felt. A _____[Blank 4] ultrasound was performed, and _____[Blank 5] were identified.

TREATMENT: I have discussed the results of the ultrasound and have recommended a laparoscopy to provide more information on the location, extent, and size of the _____[Blank 6] implants. A _____[Blank 7] sample will be sent for further testing. If possible, the endometriosis implants will be removed.

PLAN: Ms. Roberts has agreed to the laparoscopy. I have prescribed Orilissa to help with the ________[Blank 8]. My office will set up an appointment for the ________[Blank 9].

___________________________
Adam Vance, MD, Gynecology

Check your answers: ^[2]

Use the words below to fill in the medical report:

• Edema
• Blood Pressure
• Ovarian
• Menorrhagia
• Auscultation
• Murmur
• Spotting
• Chronic
• Oophoritis
• Urination
• Abdominal
• RLQ

FEMALE REPRODUCTIVE SYSTEM – MEDICAL REPORT

PATIENT NAME: Megan WESTOVER
AGE: 29
SEX: Female
DOB: November 22
DATE OF ASSESSMENT: June 4
ATTENDING PHYSICIAN: Adam Vance, MD, Gynecology

HISTORY: A 29-year-old woman complains of right _____[Blank 1] pain. She has fever with chills, nausea, and pain during _____[Blank 2] for 3 days. She is in the 4th day of her menstrual cycle and has _____[Blank 3]. She has had intermenstrual _____[Blank 4] for the last 3 menstrual cycles. She had a hysterectomy due to a breast cancer 9 years ago. She has no other history of _____[Blank 5] illness.

PHYSICAL AND EXAMINATION: VITAL SIGNS: Temperature 102.2, _____[Blank 6] 115/75, and pulse 92, regular. Respiratory rate 16. LUNGS: Normal breath sounds. HEART: No _____[Blank 7], regular rhythm. ABDOMEN: There is a tenderness to deep palpation in the _____[Blank 8]. Pain triggers when the patient bends forward. Normal to _____[Blank 9]. BACK: No flank tenderness. EXTREMITIES: Normal with no _____[Blank 10].

LABORATORY: No UTI, urinalysis done in the clinic negative.

ASSESSMENT: Rule out _____[Blank 11]. No evidence of UTI currently.

PLAN

1. CBC lab testing.
2. Pelvic ultrasound focused on _____ [Blank 12]structures, transvaginal ultrasound.
3. Begin treatment empirically with Ampicillin 500 mg daily.
4. Follow up with the patient after the blood and ultrasound results.

___________________________________
Adam Vance, MD, Gynecology

Check your answers: ^[3]

Using the words below fill in the consultation report:

• Cyanosis
• Mastectomy
• Chemotherapy
• Breast
• HEENT
• Murmurs
• Weight
• Distended
• Erythema
• Lesion

FEMALE REPRODUCTIVE SYSTEM – CONSULTATION REPORT

PATIENT NAME: Abigail LANGMAN
AGE: 51
SEX: Female
DOB: July 27
DATE OF CONSULTATION: October 8
CONSULTING PHYSICIAN: Adam Vance, MD, OB/GYN

REASON FOR CONSULTATION: Possible breast cancer.

HISTORY: Patient is a 51-year-old woman here for a check-up because of a suspicious lump that was found on her yearly mammogram. Patient is worried about possible _____[Blank 1] cancer.

PHYSICAL EXAMINATION: GENERAL: No acute distress. VITAL SIGNS: Temperature is 98.1°F. Pulse is 72, BP is 110/72 mm Hg. Respirations 16. _____[Blank 2] is 186 pounds, height is 5 feet, 8 inches. _____[Blank 3] : Eyes are equal and responsive. Ears are normal, no discharge. Nose is normal. Throat is normal and without _____[Blank 4]. LUNGS: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm, no _____[Blank 5]. ABDOMEN: Palpation is soft, not _____[Blank 6], nontender. BREAST: RIGHT: Tender to the touch on right side and has a hard lump about the size of a golf ball near the axilla. LEFT: Normal to the touch, no discomfort. EXTREMITIES: Without edema, _____[Blank 7], or clubbing.

SOCIAL HISTORY: Mother had breast cancer at the age of 48 and had a _____[Blank 8] to remove the left breast. Patient has been scheduled for yearly mammograms since the age of 45 to check for possible signs of early breast cancer. Father has a history of stage 1 rectal cancer treated with 3 rounds of _____[Blank 9]. The patient does not smoke or use recreational drugs, she does like a glass of wine 3-4 nights a week.

Patient states she is quite worried since scheduling an appointment to follow up her mammogram results. Patient has experiencing anxiety which is affecting her eating and sleeping routine.

ASSESSMENT: Patient is a 51-year-old woman here for a check-up because a suspicious lump found on her yearly mammogram. Patient is otherwise healthy and is not currently on any medications.

PLAN

1. 1. Ultrasound of the right breast.
2. 2. Biopsy of the _____[Blank 10] for pathology. Avoid overexertion or lifting of arms above shoulder height after the biopsy
3.  Follow-up appointment in 2-3 weeks for results.

________________________
Adam Vance, MD, OB/GYN

Check your answers:^[4]