Chief complaint: Further evaluation for abnormal pap smear

 

HPI

51 yo G6P6006, all NSVD, pmhx HIV+, TB, asthma, HTN, and intermittent abnormal pap smears x 23 years presents for pre-op evaluation for LEEP. Culposcopy was attempted in the clinic on 2/19/19, unsuccessfully due to inability to visualize cervix. She reports a long history of abnormal pap smear results, with a LEEP in 1998, laser in 1998 and a cone in 2002 as well as multiple colposcopys – last pap in 10/2018 CIN III. She states that until recently, she was being seen by a doctor at King’s County Hospital. In addition to the history of abnormal paps, she also reports progressively worsening stress incontinence and states her wish for an elective hysterectomy. She reports that she was scheduled multiple times for “a hysterectomy with bladder lift” at King’s County, but that the doctor repeatedly cancelled the procedure. Her LMP was in 2012 and she denies being sexually active. She also denies any abnormal uterine bleeding, known uterine fibroids, fever, chills, dysuria, N/V, change in bowel habits, chest pain or SOB at this time.

 

PMHX

HIV (2013)

HTN (2015)

TB (2003, treated)

Asthma (2002)

Stress incontinence (1992)

 

PSHX

LEEP (1998)

Laser cervical biopsy (1998)

Cervical conization (2002)

Cholecystectomy (2012)

 

Medications

Albuterol (Proventil) 4mg QID

Amlodipine 10mg qd

Dolutegravir 50mg qd

Emtricitabine-tenofovir alanfetamide 200-25 qd

Ergocalciferol 50,000 U Q 1 wk

Ibuprofen 600mg Q 6hrs PRN

Metclopromide 10mg qd

Ranitidine 150mg BID

 

Allergies

Shellfish (hives, rash)

 

FHX

Mother: DMII, alive and well

Grandmother: HTN, stroke, deceased at 89

Brother: HTN, DMII

Sister: DM II

 

SHX

She is unmarried and denies being sexually active, she reports drinking 4-5 alcoholic beverages/wk, and admits marijuana use 7x/wk. She denies tobacco use, recent travel and states that to her knowledge her vaccines are up-to-date.

 

ROS

• Constitutional: energy level good, weight is stable at 109kg height 5’9”
• HEENT:
• Occasional headaches, well-controlled with Tylenol
• Eyes: no recent changes in vision, photophobia, or glasses use
• Ears: hearing intact
• Nose: no epistaxis or obstruction
• Mouth and throat: no ulceration, hx of candidiasis, dentition intact
• Neck: no lumps, localized swelling or stiffness
• Respiratory: No SOB, cough, wheezing, hemoptysis, PE, pneumonia, TB or TB exposure
• Cardiac: HTN controlled with amlodipine x 4 years, no recent CP, palpitations, edema of hands or feet, syncope, known murmur
• Vascular: no hx of claudication, gangrene, DVT, aneurysm
• GI: admits to occasional N/V/D secondary to HIV antiviral medication, recent change in appetite, history of heart burn, jaundice, change in bowel habits, rectal bleeding
• GU: history of progressively worsening stress incontinence x 27 yrs with occasional frequency and urgency, she denies dysuria, polyuria, hematuria, nocturia, or flank pain. She is not currently sexually active, she reports hx of chlamydia that was successfully treated in 2000, she is HIV +
• Menstrual and obstetrical: LMP 2012 with occasional hot flashes, difficulty sleeping and irritability. Menarche at 12yrs. She denies vaginal discharge. She denies any postmenopausal bleeding. She is G6P6006 all NSVD.
• Neuromuscular: she reports occasional b/I knee pain for which she take ibuprofen when needed. There is no hx of seizures, stroke, syncope, memory changes
• Emotional: denies history of depression, anxiety
• Hematological: no known blood or clotting disorders
• Rheumatic: no hx of gout, rheumatic arthritis, or lupus
• Endocrine: no known diabetes or thyroid disease
• Dermatological: no new rashes or pruritus

 

PE

• VS: BP 134/85 left arm, supine position; pulse 65 regular; O₂sat 98% room air; respirations 18/min; temp 98.2°F oral; weight 102 kg
• Patient is alert and oriented x 3, appears stated age and is resting comfortably
• HEENT: normocephalic atraumatic
• Neck: trachea midline, carotids 2+ b/l
• Heart: regular rate and rhythm, no heaves, gallops, murmurs
• Lungs: CTA bilaterally
• Abdomen: soft, non-tender, bowel sounds active, no CVA tenderness
• Extremities: no edema or tenderness in LE b/l
• Skin: moist, good turgor, cap refill < 2 sec
• External genitalia: normal vulva, no lesions or excoriations
• Vaginal exam: cystocele, mucosa pink and moist, no atrophy noted
• Uterus: small, anteverted
• Cervix: difficult to visualize, appears completely flush with the vagina

 

Labs

• Blood type, A+
• CBC, CMP wnl
• Treponema pallidum Ab screen +
• RPR –
• FTA antibodies: equivocal
• Viral load not detected on last screen (10/2018)
• HgbA1C: 6.1%

 

Assessment: 51 yo G6P6, menopause since 2012 pmhx HIV+, TB, asthma, HTN with h/o abnormal paps and multiple colposcopies at King’s County Hospital, last one several years ago. Last pap 10/2018: CIN III with unsuccessful culpo attempt in clinic.

 

Plan

• NPO
• Consult with anesthesia
• Attempt colposcopy under anesthesia
• LEEP