This is an establish visit.
Do you get a level four out of this?
She is a 48-year old female here today for follow-up after a brief hospitalization back on April 12, 2008, at Inland Valley Hospital for menorrhagia. She ended up being admitted for two days, given four units of blood and was started on birth control pills and iron replacement.
She has a known history of a large uterine fibroid in the past. She has had some menorrhagia previously but has never had a significant drop in her hemoglobin. Her last measurement in January of 2007 was 11.3.
She is also concerned because her blood pressure is high today: it is 162/104, with a pulse of 90, and she is feeling a little short of breath. She awakened in the middle of the night with a nightmare.
Repeat blood pressure is 150/104.
The patient needs a referral for GYN consultation regarding either having an endometrial ablation versus a hysterectomy. I think given the size of her fibroid she is not likely a candidate for utierine artery embolization, however, that would be something to discuss with gynecologist.
Physical Exam: On exam today her lungs are clear. Her heart reveals a regular rhythm, without murmurs or gallops. She has no calf tenderness or ankle edema.
She was given business cards for Dr. Hughes and Henderson both of Medical Clinic for Women and also for Dr. Dietrich. She will call them to set up an appointment at her convenience. In the meantime recommend she obtain twice daily home blood pressure readings and update lab work, including a CBC. Will obtain her records from her hospitatlization[/B]. Will see her back for a recheck in a week.
Thank You in advance for your opion
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