History of Present Illness:
Chief Complaint Grade 1 Endometrial Cancer.
This 29 year old gravida 0 para 0 presents today for follow up after total abdominal hysterectomy, bilateral salpingo-ooophonectomy on July 15, 2020 with final pathology showing Stage 1B grade 2 Endometrial cancer (56% MMI; no lvsi). She had a CT scan earlier today showing stable abdominal and retroperitoneal adenopathy.
Background:
Ms. Reid states she has had daily vaginal bleeding for the past 2 years. Of note the bleeding progressively has worsened over the past few weeks and she presented to Lake Cumberland (Somerset) ED. An emergency D&C was completed which showed a Grade 1 endometrial adenocarcinoma per review here. Since the D&C she states her bleeding is described as light daily requiring 3-4 pads/d, but less than prior to D&C. She is currently taking Provera 10mg BID. Last year, she states she lost 80lbs (intentional weight loss) and has helped her mobility around the house.
PMH: Gallstones, LE Edema, Super Morbid Obesity (BMI=84), HTN, Bipolar, Anxiety
PSH: D&C
OB: G0
GYN History:
LMP: Unsure. Bleeding daily for last 2 years
Pap: Collected today
Contraception: None, never sexually active.
Social: Single. Has a girlfriend (lesbian relationship). Denies smoking, illicit drugs or alcohol. Lives also with 2 other roommates. Runs her own YouTube Channel as a source of income. She mentions a history of neglect as a child without further details given. Unable to climb a flight of stairs without stopping. METS=1.
FH:
Mother – Vulvar cancer.
Interval History.
She is healing well from surgery. Her incision is good. No fevers. No vaginal bleeding.
Treatment History.
Total abdominal hysterectomy, bilateral salpingo-ooophorectomy on July 15, 2020 with final pathology showing Stage 1B grade 2 Endometrial cancer (56% MMI, no lvsi). She had a scan earlier today showing stable abdominal and retroperitoneal adenopathy.
Cancer Monitoring:
Ultrasound: 05/29/2020
CT Scan: 6/17/2020
Health History:
03. Medical Hx:
Abnormal uterine bleeding;
Fatigue;
Hypertension;
04. Surgical Hx:
Hysterectomy;
Dilatation and curettage;
05. Family Hx:
Family history of cancer of vulva;
06. Social Hx:
Sexual abuse;
Tobacco:
Have you EVER used TOBACCO? “No”
Does the patient have any regular exposure to second hand smoke? “No”
Outpatient Medication/Rx Writer:
Estradiol 1 mg oral tablet: 1 tab(s) orally once a day
Sertraline 50 mg oral tablet: 1 tab(s) orally once a day
lamotrigine 150 mg oral tablet: 1 tab(s) orally once a day
Allergies/Intolerances:
No known allergies
