Gynecological Assessment Letter

Thank you for referring Anna for a gynecological assessment.  

Anna is a pleasant female patient.  

Reason for Consult  
- Breast biopsy follow-up and ovarian cyst monitoring  

History of Present Illness (HPI)  
Anna is following up for monitoring of a breast biopsy and ovarian cysts.  
- Breast Biopsy Monitoring: Recent mammogram and core biopsy from March 8th indicate benign findings, showing benign breast tissue with dense fibrosis and no evidence of atypia or carcinoma. She has been advised to repeat an ultrasound in six months.  
- Ovarian Cysts: The last ultrasound showed stable complex cysts, and she is awaiting an MRI appointment, which has been pending since November 2020. Tumor marker results from January 2nd were negative for malignancy. She reports no symptoms related to her ovaries, including no pain or discomfort.  
- Fatigue: Anna reports feeling tired, which she attributes to a recent move and weather conditions. She denies any recent weight changes and has not experienced any other concerning symptoms.  

Past Obstetrical and Gynecological History  
- Mammogram: March 8th, benign findings with dense fibrosis, no evidence of atypia or carcinoma  

Past Medical History  
- Monitoring for breast biopsy and ovarian cysts  

Past Surgical History  
- None  

Medications  
- None  

Allergies  
- No known drug allergies  

Social History  
- Recently relocated and associates fatigue with the move and weather conditions  

Family History  
- None  

Investigations  
Labs:  
  - Tumor marker results from January 2nd were negative for malignancy  
Imaging:  
  - Mammogram and core biopsy from March 8th indicate benign findings, showing benign breast tissue with dense fibrosis and no evidence of atypia or carcinoma  
Pending Investigations:  
  - MRI appointment for ovarian cysts, pending since November 2020  

Physical Examination  
- Vitals: Not available  

Impression and Recommendations  
In summary, this is a female patient with:  

Problems and Plan:  
1. Benign breast tissue with dense fibrosis:  
   - Diagnosis: Benign findings from mammogram and core biopsy  
   - Plan: Repeat ultrasound in six months. Referral for ultrasound has been sent to Regional Imaging Center, and the patient has been provided with contact information to schedule the appointment.  

2. Stable complex ovarian cysts:  
   - Diagnosis: Stable complex cysts as per the last ultrasound, tumor markers negative for malignancy  
   - Plan: MRI appointment is still pending. The patient is instructed to follow up with the office if no updates are received within one month. Once the ultrasound results are available, the physician will review them and follow up with the patient accordingly.  

Follow-Up Plan:  
- Patient advised to call and arrange the ultrasound at their earliest convenience.  
- Patient instructed to contact the office two weeks after the ultrasound if they have not received any updates by that time.  

Thank you again for referring Anna. Please do not hesitate to contact me if you require any further information or clarification.  

Yours sincerely,  
Dr. Karen Sanderson  
Regional Gynecology