bmanus
Guru
CC: abnormal vulvar and vaginal biopsy result
HPI: is a pleasant 38 yo G4P2-0-2-2 female who presented with biopsy proven VIN 1 and VaIN1. She went to planned parenthood a months ago for IUD insertion. Per patient, pelvic exam revealed a polyp like structure obstructing cervical OS. IUD was eventually placed. She went back a week later for f/u and polyp was not found on exam, however, valvar and vaginal biopsy was performed for palpable bumpiness in the area. She has a long history of HPV infection and a history of genital warts 11 years ago. Her biopsy (10/25/12) showed VIN-1 and VaIN1. She feels sore in her perineal area but otherwise does not have other complaints.
She has regular periods. She has not had a PAP test for years. She just had a HIV testing a month ago and per patient it was negative. She is a nonsmoker.
PMH:
Hx of HPV
Anemia
Pneumonia in 2001 and 2006
Frequent pyelonephritis that required hospitalization
PSxH:
Surgery for right kidney stone, complication was postop bleeding that required extended hospital stay 2010
FH:
Mother: 68, alive with recurrent ovarian cancer, initially diagnosed at age 63
M. Aunt: breast cancer survivor, 53, diagnosed at age 38
MGM: uterine cancer/breast cancer, deceased
PFM: breast cancer survivor
M. Great aunt: ovarian cancer, deceased.
SH:
Divorced, works at a wire store. Nonsmoker. Dose not drink. Hx of marijuana, LSD, Speed and heroin long time ago in college.
OB/Gyn hx:
G4P2-0-2-2, NSVD x 2 15 and 3 years ago. Coitarche 15; number of lifetime partners 9; currently sexually active; nenarche 12; lmp: 2 weeks ago. Birth control IUD. Rest of gyn hx see HPI.
ROS:
A 14-system ROS was performed, in addition to the elements documented in HPI was positive for the following: unable to sleep, weight changes, bleeding tendency, frequent colds, frequent UTI, abdominal pain, swollen feet, depression, partner has genital warts, bleeding with intercourse.
PE:
Gen: pleasant female in NAD
HEENT: normocephalic, anicteric, EOMI
Neck: supple, no thyromegaly
CV: RRR, no m/r/g
Lungs: CTAB
Abd: soft, nontender
Ext: WWP, no edema
External genitalia: normal contour, visible raised roughness on distal vaginal wall and vulvar area, Subtle hypopigmentation noted in vaginal mucosa. Cervix appears grossly normal with no lesions.
Pathology:
10/25 vulvar biopsy- VIN I
10/25 vaginal biopsy-VaIN1
Assessment and plan:
38 yo G4P2 female with history of genital HPV infection
Recent biopsy proven VIN I and VaIN1
Genetic susceptibility to ovarian cancer
- Discussed topical treatment with Efudex. PARQ held and she agrees to proceed with treatment. Instruction given in detail. She will use 1g intravaginally and on her vulvar area, once a week for 10 weeks. We will see her in 5 weeks for mid-treatment check.
- We discussed in length her her family' risk for hereditary Breast and Ovarian Cancer syndrome and her increased risk for developing ovarian cancer and breast cancer. we discussed that her lifetime risk to develop ovarian cancer can be more than 8-12% as compared to 1 to 2% general population lifetime risk to develop ovarian cancer. Her risk for developing breast cancer is also increased. A genetic counseling will perform a complete cancer risk-analysis and discuss further testing.
I think is a 99203. any help would be greatly appreciated.
Beth Manus
HPI: is a pleasant 38 yo G4P2-0-2-2 female who presented with biopsy proven VIN 1 and VaIN1. She went to planned parenthood a months ago for IUD insertion. Per patient, pelvic exam revealed a polyp like structure obstructing cervical OS. IUD was eventually placed. She went back a week later for f/u and polyp was not found on exam, however, valvar and vaginal biopsy was performed for palpable bumpiness in the area. She has a long history of HPV infection and a history of genital warts 11 years ago. Her biopsy (10/25/12) showed VIN-1 and VaIN1. She feels sore in her perineal area but otherwise does not have other complaints.
She has regular periods. She has not had a PAP test for years. She just had a HIV testing a month ago and per patient it was negative. She is a nonsmoker.
PMH:
Hx of HPV
Anemia
Pneumonia in 2001 and 2006
Frequent pyelonephritis that required hospitalization
PSxH:
Surgery for right kidney stone, complication was postop bleeding that required extended hospital stay 2010
FH:
Mother: 68, alive with recurrent ovarian cancer, initially diagnosed at age 63
M. Aunt: breast cancer survivor, 53, diagnosed at age 38
MGM: uterine cancer/breast cancer, deceased
PFM: breast cancer survivor
M. Great aunt: ovarian cancer, deceased.
SH:
Divorced, works at a wire store. Nonsmoker. Dose not drink. Hx of marijuana, LSD, Speed and heroin long time ago in college.
OB/Gyn hx:
G4P2-0-2-2, NSVD x 2 15 and 3 years ago. Coitarche 15; number of lifetime partners 9; currently sexually active; nenarche 12; lmp: 2 weeks ago. Birth control IUD. Rest of gyn hx see HPI.
ROS:
A 14-system ROS was performed, in addition to the elements documented in HPI was positive for the following: unable to sleep, weight changes, bleeding tendency, frequent colds, frequent UTI, abdominal pain, swollen feet, depression, partner has genital warts, bleeding with intercourse.
PE:
Gen: pleasant female in NAD
HEENT: normocephalic, anicteric, EOMI
Neck: supple, no thyromegaly
CV: RRR, no m/r/g
Lungs: CTAB
Abd: soft, nontender
Ext: WWP, no edema
External genitalia: normal contour, visible raised roughness on distal vaginal wall and vulvar area, Subtle hypopigmentation noted in vaginal mucosa. Cervix appears grossly normal with no lesions.
Pathology:
10/25 vulvar biopsy- VIN I
10/25 vaginal biopsy-VaIN1
Assessment and plan:
38 yo G4P2 female with history of genital HPV infection
Recent biopsy proven VIN I and VaIN1
Genetic susceptibility to ovarian cancer
- Discussed topical treatment with Efudex. PARQ held and she agrees to proceed with treatment. Instruction given in detail. She will use 1g intravaginally and on her vulvar area, once a week for 10 weeks. We will see her in 5 weeks for mid-treatment check.
- We discussed in length her her family' risk for hereditary Breast and Ovarian Cancer syndrome and her increased risk for developing ovarian cancer and breast cancer. we discussed that her lifetime risk to develop ovarian cancer can be more than 8-12% as compared to 1 to 2% general population lifetime risk to develop ovarian cancer. Her risk for developing breast cancer is also increased. A genetic counseling will perform a complete cancer risk-analysis and discuss further testing.
I think is a 99203. any help would be greatly appreciated.
Beth Manus