FAMILY HISTORY: Father has high blood pressure, high cholesterol, coronary artery disease. Maternal grandmother had breast...
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FAMILY HISTORY: Father has high blood pressure, high cholesterol, coronary artery disease. Maternal grandmother had breast cancer. No ovarian or colon cancer history. Father is diabetic. No family history of thyroid disorders or osteoporosis. No depression or mental health issues. REVIEW OF SYSTEMS: No current HEENT, respiratory, cardiovascular, breast, or Gl problems. Lower abdominal pain and vaginal bleeding as noted above on a couple of instances. No pain during intercourse. No neurological, endocrine, or integumentary problems. No further depression symptoms. PHYSICAL EXAMINATION: Declines the presence of a chaperone in the room today. Blood pressure 108/78. Weight 208 pounds. Height: 5 feet 5 inches. Thyroid is normal to palpation without enlargement. Cervical nodes are negative. Lungs are clear to auscultation without rales or wheezes. Heart: Regular rate and rhythm without murmurs. Breasts are normal to inspection and bilaterally symmetrical. Normal to palpation. No nipple discharge. Negative axillary nodes. Negative CVAT. Abdomen is soft without organomegaly or hernia. Vulva is normal to inspection. Normal hair distribution. Negative BUS. Negative inguinal nodes. Vagina is clean with a scant amount of creamy discharge. On opening of the speculum to visualize the cervix, the patient complains of some discomfort and there is a slight amount of oozing at the posterior aspect of the cervical apex under the cervical stump. A Pap smear was obtained. Bimanual exam shows tenderness with deep penetration into the vagina and tenderness with cervical stump movement anteriorly. No masses palpated in the cul-de-sac or with bimanual exam. Skin is warm and dry. Distal pulses are equal. No edema of the extremities. ASSESSMENT: 1. Gynecologic examination with Pap. 2. Vaginal tenderness and slight vaginal bleeding, post hysterectomy. 3. Health maintenance issues. PLAN: 1. We will notify her of her Pap results within two weeks. 2. We will consult with OB/GYN regarding these symptoms. I did give the patient two samples of vaginal Premarin cream and advised that she apply on applicator weekly to thicken the vaginal skin. 3. Mammogram will be scheduled in the near future. Fasting lab work is managed by primary physician's office as is her cholesterol. 4. Reinforced that she do a monthly breast exam, maintain an adequate calcium intake, and encouraged her efforts towards resuming a Weight Watcher's food plan and consistent exercise regimen. 5. Return to the clinic p.r.n. and for gynecologic care. Pathology Report later Indicated: Abnormal Pap cells some benign changes Your work + Add work Assigned 5:33 PM Wed Dec 6 Due today, 11:59 PM 6: Office Visit 10 points Add class comment ... 10% Report LOCATION: Outpatient, Clinic PATIENT: Emma Davis PHYSICIAN: Andy Martinez, M.D. CHIEF COMPLAINT: Yearly physical and pap. SUBJECTIVE: Emma is a 44-year-old white female, four previous pregnancies, two children, returns today for a GYN exam and Pap smear. She mentions some concerns about occasional right lower quadrant pain and slight vaginal bleeding that she has had off and on for the last couple of weeks. She did have a urinalysis done that showed no blood in the urine. She states the discharge is very minimal and she has not found any contributing factors. CURRENT HORMONE THERAPY: Nothing. MENSTRUAL HISTORY: She had a hysterectomy for a bicornuate uterus and menorrhagia. The cervix was adhered to the bladder so a cervical stub has been left. She has no hot flashes or sleep disturbances. She has never had a previous abnormal pap smear. MEDICAL HISTORY: Chronic illnesses include gastroesphageal reflux disease, high cholesterol, anxiety, history of one kidney, and history of irritable bowel. SURGERIES: 1. Hysterectomy. 2. Two cesarean sections. HOSPITALIZATIONS: For surgery and childbirth only. SOCIAL HISTORY: She is married and has no concerns of STD risks or abuse in this 23-year relationship. She feels that her diet has been fairly healthy. She is down over 15 pounds with healthy eating over the last few months and hoping to lose more. She has two to three servings of calcium a day and no caffeine. She does continue to smoke rarely and has minimal secondhand smoke exposure. She has no alcohol intake. She is trying to walk consistently for exercise. She does wear a seatbelt, does use a sunscreen, and does do a self-breast exam. Your work Assigned + Add work FAMILY HISTORY: Father has high blood pressure, high cholesterol, coronary artery disease. Maternal grandmother had breast cancer. No ovarian or colon cancer history. Father is diabetic. No family history of thyroid disorders or osteoporosis. No depression or mental health issues. REVIEW OF SYSTEMS: No current HEENT, respiratory, cardiovascular, breast, or Gl problems. Lower abdominal pain and vaginal bleeding as noted above on a couple of instances. No pain during intercourse. No neurological, endocrine, or integumentary problems. No further depression symptoms. PHYSICAL EXAMINATION: Declines the presence of a chaperone in the room today. Blood pressure 108/78. Weight 208 pounds. Height: 5 feet 5 inches. Thyroid is normal to palpation without enlargement. Cervical nodes are negative. Lungs are clear to auscultation without rales or wheezes. Heart: Regular rate and rhythm without murmurs. Breasts are normal to inspection and bilaterally symmetrical. Normal to palpation. No nipple discharge. Negative axillary nodes. Negative CVAT. Abdomen is soft without organomegaly or hernia. Vulva is normal to inspection. Normal hair distribution. Negative BUS. Negative inguinal nodes. Vagina is clean with a scant amount of creamy discharge. On opening of the speculum to visualize the cervix, the patient complains of some discomfort and there is a slight amount of oozing at the posterior aspect of the cervical apex under the cervical stump. A Pap smear was obtained. Bimanual exam shows tenderness with deep penetration into the vagina and tenderness with cervical stump movement anteriorly. No masses palpated in the cul-de-sac or with bimanual exam. Skin is warm and dry. Distal pulses are equal. No edema of the extremities. ASSESSMENT: 1. Gynecologic examination with Pap. 2. Vaginal tenderness and slight vaginal bleeding, post hysterectomy. 3. Health maintenance issues. PLAN: 1. We will notify her of her Pap results within two weeks. 2. We will consult with OB/GYN regarding these symptoms. I did give the patient two samples of vaginal Premarin cream and advised that she apply on applicator weekly to thicken the vaginal skin. 3. Mammogram will be scheduled in the near future. Fasting lab work is managed by primary physician's office as is her cholesterol. 4. Reinforced that she do a monthly breast exam, maintain an adequate calcium intake, and encouraged her efforts towards resuming a Weight Watcher's food plan and consistent exercise regimen. 5. Return to the clinic p.r.n. and for gynecologic care. Pathology Report later Indicated: Abnormal Pap cells some benign changes Your work + Add work Assigned 5:33 PM Wed Dec 6 Due today, 11:59 PM 6: Office Visit 10 points Add class comment ... 10% Report LOCATION: Outpatient, Clinic PATIENT: Emma Davis PHYSICIAN: Andy Martinez, M.D. CHIEF COMPLAINT: Yearly physical and pap. SUBJECTIVE: Emma is a 44-year-old white female, four previous pregnancies, two children, returns today for a GYN exam and Pap smear. She mentions some concerns about occasional right lower quadrant pain and slight vaginal bleeding that she has had off and on for the last couple of weeks. She did have a urinalysis done that showed no blood in the urine. She states the discharge is very minimal and she has not found any contributing factors. CURRENT HORMONE THERAPY: Nothing. MENSTRUAL HISTORY: She had a hysterectomy for a bicornuate uterus and menorrhagia. The cervix was adhered to the bladder so a cervical stub has been left. She has no hot flashes or sleep disturbances. She has never had a previous abnormal pap smear. MEDICAL HISTORY: Chronic illnesses include gastroesphageal reflux disease, high cholesterol, anxiety, history of one kidney, and history of irritable bowel. SURGERIES: 1. Hysterectomy. 2. Two cesarean sections. HOSPITALIZATIONS: For surgery and childbirth only. SOCIAL HISTORY: She is married and has no concerns of STD risks or abuse in this 23-year relationship. She feels that her diet has been fairly healthy. She is down over 15 pounds with healthy eating over the last few months and hoping to lose more. She has two to three servings of calcium a day and no caffeine. She does continue to smoke rarely and has minimal secondhand smoke exposure. She has no alcohol intake. She is trying to walk consistently for exercise. She does wear a seatbelt, does use a sunscreen, and does do a self-breast exam. Your work Assigned + Add work
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