Medical project

Letter 11

Letterhead

Date: July 17 2014

Winthrop G. Macdonald, MD

5700 Fifth Ave

Philadelphia Pa 17532

Dear Mac

RE: Laverne Lampe

Thank you for referring Mrs Lampe to my office for gynecological evaluation.

She was first seen on November 10, 2103, but this report was intentionally delayed until the results from the endometrial biopsy where obtained.

At the time of the initial visit Mrs Lampe stated that she had had no menses for 6 to 7 months. However, beginning about 3 to 4 weeks ago she developed a clear discharge which was blood-tinged during the week of her visit. She denied any pain associated with this bleeding.

As you are familiar with her past history and review of systems these will not be reiterated at this time.

Gynecological examination revealed the following: Breasts: Symmetrical. No masses, tenderness, or induration. No axillary adenopathy. Abdomen: Flat. Liver, spleen, and kidneys not felt. No masses, tenderness, or hernias. Pelvic: External genitalia normal with normal female escutcheon. The introitis is parous. Perinea is intact. Bartholin and skene urethral glands are normal. There is no significant cystocel or rectocel. The vaginal mucosa is healthy in appearance. Direct visualization of the cervix revealed a small cervical polyp at six o’clock, which was removed. Bimanual palpation revealed the uterus to be retro-displaced, symmetrical in contour and slightly enlarged. The adnexal regions and the culdesac felt normal. As noted above, the cervical polyp was removed.

July 17 2014

RE: Laverne Lampe

Page 2

An endometrial biopsy was done, and the uterus measured 9 CM in depth, which represents a slight enlargement. A large amount of hyperplastic/appearing tissue was obtained on the biopsy. As you know from your copy of the biopsy report, she does have a grade three cystic endometrial hyperplasia with focal adenomatous hyperplasia.

This information was conveyed to Mrs Lampe, and the treatment indicated is a curettage. While I doubt if she has a malignancy, removal of all this hyperplastic tissue is indicated to make sure she does not have an in situcarcinoma present. She is a very apprehensive woman, and at this time, it is unknown whether she will proceed with the recommended surgery. If she does return for the curettage, I will see that you receive a copy of the surgical dictation and the pathology report.

Thank you again for your kindness in referring Mrs Lampe and for allowing me to assist with her care.

Warmest personal regards.

Very truly yours

Martin P. Douglas, MD

Copy: Frank Horowitz MD