Woman – Complete

provided by patient SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA

Purpose of Visit/CC: annual screening new problem follow up on abnormal

Breast: pain swelling lump discharge skin changes abnormal imaging biopsy surgery family history no sx reported

GI: upper abd pain lower abd pain diarrhea constipation nausea/vomiting no sx reported

Menstrual: irregular menstruation heavy menses painful menses spotting missed menopause no sx reported

LMP:

Urinary: burning frequency pain with urination blood in urine back pain stress incontinence urge incontinence no sx reported

Vaginal Sx: does not report clear discharge thick discharge yellow discharge brown discharge itching skin lesions painful intercourse postcoital bleeding prolapse vaginal bleeding vaginal clots vaginal tissue started several days ago started today

Sexual Hx: declined N/A active inactive no new partners known/suspected exposure inconsistent condom use new partner partner w STI non-monogamous partner vaginal oral anal previous STI

Last unprotected intercourse:

Birth Control/HRT: none BCP Depo implant IUD BTL condoms

Smoking: no yes

HPI:
Recent History: stress travel new sexual partner injury PCP/UC visit ER visit hospitalization/surgery/procedure new medications antibiotic use diagnostic study non-contributory

Symptoms: started today started days ago started weeks ago started months ago increasing in severity remaining constant decreasing in severity constant come and go cyclic worse with menses worse with caffeine none reported

Imaging: mammogram UTD normal abnormal not UTD ultrasound MRI

PAP:
N/A normal abnormal unsatisfactory EC/TZ component present EC/TZ component absent ASC-US LSIL ASC-H HSIL AGC AIS CIS HPV POS HPV NEG

Family Hx:
N/A breast ca ovarian ca colon ca

PMH:
reviewed
noncontributory frequent UTIs kidney stones incontinence ovarian cyst endometriosis fibroids breast ca DM immunosuppression

Pregnancy:

pregnancy

PSH:
breast biopsy breast implants breast reduction CS salpingo-oophorectomy hysterectomy colposcopy D&C

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL:

fever night sweats hot flashes unintentional wt loss
HEAD/FACE:

headache scalp swelling trauma facial numbness
EYES:

decrease in vision halos dryness redness discharge
EARS:

pain pressure discharge wax hearing loss ringing
NOSE:

discharge PND congestion sinus pressure snoring bleeding
MOUTH:

sores dryness tongue pain/swelling toothache jaw pain/clicking changes in taste
THROAT:

sore throat odynophagia dysphagia hoarseness globus
NECK:

pain stiffness swelling swollen glands
CV:

chest pain/pressure SOB palpitations lightheadedness fainting exertional dyspnea orthopnea rapid wt gain ankle swelling ankle discoloration varicose veins leg cramps
CHEST/RESPIRATORY:

cough phlegm wheezing pain w/ breathing rib pain breast swelling/lump
MSK:

myalgias neck pain back pain shoulder pain hip pain knee pain chronic pain/meds joint pain/deformity localized muscle/soft tissue pain/swelling
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness blackouts speech difficulty tremor seizures urinary/bowel changes tingling/numbness
PSYCH:

irritability confusion withdrawal depression apathy anxiety mood swings memory loss insomnia
ENDO:

cold intolerance skin dryness hair loss
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia
ALLERGIES/IMMUNE:

atopy food allergies autoimmune dz h/o cancer
DERM:

dryness pruritus rash hives redness swelling wounds

Appearance:
well-appearing no signs of discomfort visible while sitting in chair no signs of discomfort visible while ambulating & getting on/off exam table normal built heavy built emaciated frail ill-appearing tired-looking short of breath diaphoretic good hygiene disheveled bizarre clothes body odor drowsy appears impaired slumped

Head/Face:
normocephalic, atraumatic symmetrical face CN grossly intact plethoric face alopecia facial droop

Eyes:
clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact cornea(s) clear glasses contacts conjunctival injection epiphora

Ears:
symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or discharge TMs normal in appearance

Nose:
nares patent bilaterally septum midline no facial tenderness mucosa pink & moist swollen & boggy mucosa mucosal congestion clear discharge

Mouth:
tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions upper denture lower denture poor dentition oral ulcers gum swelling tooth decay

Throat:
normal voice patent pharynx w/o swelling or exudates uvula midline clear pharynx w/o exudates hoarseness pharyngeal erythema w/o exudates pharyngeal crowding

Neck:
symmetric with free painless ROM and no masses supple no LAD no bruit or JVD anterior LAD posterior LAD thyroid enlargement nuchal tenderness

Lungs:
normal work of breathing, symmetrical chest expansion, no stridor clear and equal breath sounds bilaterally SOB decreased bilaterally wheezing crackles

Right Breast:

implant density skin changes tenderness nipple changes nipple discharge mass axillary LAD supraclavicular LAD infraclavicular LAD

Left Breast:

implant density skin changes tenderness nipple changes nipple discharge mass axillary LAD supraclavicular LAD infraclavicular LAD

Mass:
none r breast left breast round oval irregular well-defined margins ill-defined margins less than 1 cm 1 to 3 cm larger than 3 cm soft firm rubbery hard fixed mobile

CV:
regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm systolic murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen:
not examined normal visual inspection, no distension normal active bowel sounds soft non-tender protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG direct non-rebound tenderness colostomy in situ

MSK:
no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature & ROM in C- & L-spine for patient’s age non-tender C-spine with good ROM non-tender L-spine with good ROM strength, tone, & bulk symmetrical & grossly intact

Neuro:
normal concentration and attention memory grossly intact balance & coordination grossly intact normal speech no gross motor deficits sensation symmetrical & grossly intact extremities strong w/o atrophy, tremor or fasciculations reflexes normoactive antalgic gait wide gait shuffling gait

Skin:
grossly intact, no rashes no bruises normal turgor tattoos body piercings poor turgor dry sweaty

Pelvic Exam:
normal below declined

Vulva:
normal atrophy discharge condylomata

Vagina:
normal cystocele rectocele Bartholin's erythema atrophy milky discharge curdy discharge greenish/yellowish discharge active bleeding clots tissue in vault

Cervix:
normal non-tender motion tenderness erosions Nabothian cyst discharge

Uterus:
normal tenderness mass enlarged

Adnexa:
non-tender tenderness enlargement masses

Rectal:
declined normal tone hemorrhoids masses

Behavior:
calm pleasant respectful cooperative with exam exam limited by urgency exam limited by poor cooperation exam limited by safety concerns guarded anxious fearful suspicious hypervigilant irritable frustrated restless labile sighing crying agitated raising voice defensive argumentative hostile forceful intense euphoric demanding particular medication, test, referral, or accommodation withdrawn indifferent appears to be responding to internal psychotic process

Psychomotor Activity:
no involuntary movements tremor tardive dyskinesia tics bradykinetic fidgeting picking skin twirling hair cracking knuckles threatening posture/movement grimacing, furrowing eyebrows tightening jaw breathing hard shaking extremities clenching fists intense staring standing up and/or pacing opening door to hallway exited exam room during exam

Speech:
clear & coherent normal rate & rhythm slurred monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured repetitive questions cursing, swearing criticisms of staff verbal threats

Thought Process:
organized/linear/logical circumstantial tangential perseveration flight of ideas preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others staff splitting delusions paranoid ideation

UA:
non-specific changes normal suggestive of UTI leukocytes nitrites glucose blood declined urine cx sent out

hcg:
N/A positive home test negative clinic test positive clinic test declined

A/P:

DX:
abdominal pain
abnormal pap
abortion
abscess
appendicitis
blighted ovum
breast mass
cervicitis
contusion to breast
discomfort of pregnancy
discomfort of pregnancy
dysfunctional uterine bleeding
ectopic pregnancy
endometritis
fetal demise
fibrocystic breast disease
herpes genitalis
high risk cervical neoplasm
incontinence of urine
intrauterine pregnancy
low risk cervical neoplasm
mastitis
menopause
ovarian cyst
paget's breast disease
pelvic pain
pid
prolactinemia
pyelonephritis
threatened abortion
ureterolithiasis
urinary tract infection
vaginal bleeding
vaginosis

PLAN OF CARE:
POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions verbalized understanding of and agreement with POC, discharge & f/u instructions patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere

OUTSIDE LABS:
PAP urine BV swab CBC CMP STI

RX:
none ABX Pyridium 100 mg TID #6 Rx for suspected vaginosis Rx for suspected STI electronic paper given to MA to be transmitted to pharmacy

REVIEWED:
MA notes previous visits PMP laboratory/diagnostic studies

INSTRUCTED ON:
vital signs,exam & testing findings reporting medication side effects to clinic immediately appropriate follow up with PCP weight reduction dietary changes exercise family planning contraceptive options emergency contraception safe sex SBE mammogram if older than forty osteoporosis prevention & screening smoking cessation

BARRIERS TO CARE:
none identified during visit poor cooperation with exam lack of motivation negative attitude to diagnostic impression & proposed tx failed to obtain old records failed to complete referrals or testing failed to bring medications for med review poor compliance with medication regimen incomplete history vague shifting complaints history not supported by objective findings multiple comorbidities recent hospitalization polypharmacy lack of interest in nonpharmacologic therapies overwhelming focus on Rx drugs medication use in response to environmental stress intolerance of multiple meds overreliance on short-acting meds multiple office contacts frequent ER/UC visits altered mental status hostile/disruptive behavior active psychiatric diagnosis alcohol or substance use social/cultural barriers victim of abuse

DISPOSITION:
RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN RTC 1 week RTC 6 months RTC 12 months screening mammo diagnostic mammo diagnostic ultrasound surgeon GYN referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left clinic before being discharged asked to leave clinic

Woman – Complete

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