General Gynaecology Follow Up

Subjective:
Chief Complaint:
Postmenopausal symptoms and recurrent bladder infections.

History of Present Illness:
Linda is a 64-year-old female presenting for follow-up regarding management of postmenopausal symptoms and recurrent bladder infections. She has a history of hysterectomy and bilateral salpingo-oophorectomy performed at age 28 and has been on long-term hormone therapy. She reports experiencing hot flashes when she discontinues estrogen therapy. Provera was discontinued on June 18, as it was deemed unnecessary due to her lack of a uterus, and she has not noticed any difference since its discontinuation. Vaginal estrogen cream was recently initiated to address her recurrent bladder infections, which have persisted despite prior urological evaluations. She has taken her initial dose of vaginal estrogen cream and reports no adverse effects. She continues to experience recurrent bladder infections, and the efficacy of the vaginal estrogen cream in reducing these episodes will be reassessed in three months.

Past Surgical History:
Linda underwent a total hysterectomy and bilateral salpingo-oophorectomy at the age of 28. The specific surgeon and facility are not documented. There are no reported postoperative complications.

Past Medical History:
Linda has a history of long-term hormone therapy following surgical menopause due to hysterectomy and bilateral salpingo-oophorectomy. She has experienced recurrent bladder infections over several years, for which she has undergone urological assessment. She has been compliant with prescribed hormone therapy, including estrogen and previously medroxyprogesterone acetate, which was discontinued as it was not indicated in the absence of a uterus. There is no documentation of missed appointments or non-compliance with medical advice.

The Review of Systems:
Constitutional – no fever, chills, weight loss, weight gain, night sweats, fatigue
Genito Urinary – no dysuria, hematuria, frequency, urgency, genital sores, abnormal discharge, or abnormal bleeding
Gastrointestinal – no nausea, vomiting, diarrhea, constipation, or abdominal pain
Neurological – no headaches, dizziness, or vision changes

Current Medications:
Linda is currently taking conjugated estrogens 0.3 milligrams orally and has recently initiated vaginal estrogen cream.

Allergies:
No new allergies have been reported or documented for Linda.

Gynecologic History:
Linda has a history of surgical menopause following total hysterectomy and bilateral salpingo-oophorectomy at age 28. She has been on long-term systemic estrogen therapy. She was previously taking medroxyprogesterone acetate, which was discontinued due to the absence of a uterus. She has recently initiated local vaginal estrogen therapy for recurrent urinary tract infections. There is no documentation regarding Pap smear history, sexually transmitted infections, or contraceptive use.

Objective:
Physical Examination:
General – Appears well, alert, no acute distress
Abdomen – Soft, non-tender, no distension, normal bowel sounds
Genito Urinary – External genitalia demonstrate moderate atrophic changes, no inguinal adenopathy, no abnormal discharge or lesions, bimanual exam normal, no adnexal tenderness or masses, vaginal vault appears healthy, urethra is slightly telescoped, no significant prolapse, cervix absent due to prior hysterectomy
Cardiovascular – Heart rate regular, S1S2 normal, no murmurs
Respiratory – Lungs clear to auscultation bilaterally, no wheezes or crackles

Assessment:
Clinical Impression:
Linda presents for follow-up of postmenopausal symptoms and recurrent urinary tract infections. She continues to experience vasomotor symptoms when estrogen therapy is discontinued. There is a history of recurrent urinary tract infections despite prior urological evaluation. Physical examination reveals moderate vulvovaginal atrophy and a healthy vaginal vault without significant prolapse. No adverse effects have been reported with the initiation of vaginal estrogen cream.

Problem:
1. Postmenopausal symptoms (627.2), including vasomotor instability
2. Recurrent urinary tract infections (595.9)
3. Genitourinary syndrome of menopause

Plan:
Orders and Referrals: If there is no reduction in the frequency of urinary tract infections within three months, Linda will be re-referred to urology for further evaluation.
Treatments: Continue conjugated estrogens 0.3 milligrams orally as previously prescribed. Continue long-term use of vaginal estrogen cream to address genitourinary atrophy and recurrent urinary tract infections.
Patient Education: Linda was advised regarding the importance of adherence to local estrogen therapy for prevention of recurrent urinary tract infections and management of atrophic symptoms.
Follow Up: Reassessment of urinary tract infection frequency and symptom control in three months or sooner if symptoms worsen.