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Subjective (S)
Patient demographics:
Initials: T.O.
Age: 36
Ethnicity: Caucasian
Gender: Female
Relationship of informant (if not the patient): N/A
General:
Weight gain, fatigue. Denies weight loss, denies fever, denies
chills.
Eyes:
Denies blurred vision, excessive tearing, pain, or trauma.
Last eye exam six month ago, report 20/20 vision in both eyes,
does not wear glasses or contacts.
Ears, nose, mouth and throat:
Denies changes in hearing. Denies changes in smell. Denies
nasal discharge, or bleeding. Denies recent or previous injury to
ear, nose or throat. Last dental exam was 2 months ago. No
dental carries reported. She does have a permanent crown on
the upper left second molar. She reports brushing and flossing
daily. Does not smoke or use oral tobacco products. Denies sore
throat, hoarseness or dysphagia.
Cardiovascular:
Denies regular sustained aerobic exercise routine. Denies history
or diagnosis of murmurs, denies chest pain, palpitations,
swelling, or shortness of breath. She denies high blood pressure,
and does not report symptoms of elevated BP such as headache,
dizziness, or changes in vision. No prior EKG at this office.
Respiratory:
Denies history of pneumonia or tuberculosis. She has never
smoked. Denies difficulty breathing, cough, wheezing or
hemoptysis. No prior chest x-ray per patient.
Gastrointestinal:
Denies heartburn, abdominal pain, changes in bowel habits or
stools, nausea, vomiting, diarrhea, constipation or bleeding per
rectum. Denies hemorrhoids. She does try to eat healthy, and
consume 2-3 portions of fruits and vegetable per day. She also
tries to drink plenty of water.
Genitourinary:
Denies difficulty urinating, denies pain with urination, denies
urinary frequency, urinary urgency or burning. She is sexually
active with her husband. Denies pain with intercourse. Tubal
ligation for contraception. Denies abnormal vaginal discharge.
Denies vaginal itching. Denies history of STDs. Irregular cycles
for the past 2-3 months. Per patient her cycles began at 11 years
old and were regular, lasting about 7 days, with 28 days between
each cycle. She reports increase in bleeding within the past few
months during her periods, having to change her tampon every
3-4 hours. She denies dysmenorrhea. But within the past 2-3
months, her cycles have been occasionally irregular, with
episodes of heavier bleeding lasting 7 days, but with 2-week
intervals at times between periods, instead of normal 28 days.
LMP 11/06/16. Denies current HRT. Last PAP test was 10/27/16
and normal. She is a G 3 P 3. She has had 3 C-Sections.
Musculoskeletal:
Denies regular sustained aerobic exercise routine. She does do a
lot of running around with her children. She does wear a seat
belt in vehicles. Denies joint pain, swelling, decrease in range of
motion, or numbness to extremities.
Integumentary:
Denies rashes, hair loss, easily bruising. Denies nail deformities.
Neurologic:
Denies muscle weaknesses, parasthesias, and involuntary
muscle movements or tremors. Denies loss of memory, seizures,
and/or headaches.
Psychiatric:
Depression. Denies irritability, mood changes, anxiety, insomnia,
and/or suicidal thoughts.
Endocrine:
Weight gain, hot flashes, and night sweats. Denies polydipsia,
polyuria, and/or polyphagia.
Hematologic/ lymphatic:
Fatigue, unusual vaginal bleeding. Denies unusual bruising.
Denies swollen or tender glands.
Allergic/ immunologic:
Denies seasonal allergies or prior allergy testing. Denies history
of exposure to blood or bodily fluids. Denies immunosuppression.
Denies prior use of steroids.
Objective (O):
Physical Exam:
Constitutional:
A 36-year-old white, well-nourished, pleasant female presents
today for follow-up of ultrasound and lab work. She is alert and
oriented, and seated on the exam table.
Vital signs
o Temp: 97.4 degrees F (Tympanic)
o BP: 127/88 (seated, left arm, manual)
o Pulse: 68
o Pulse ox: 98% (Room Air)
o RR: 16
o HT: 60
o WT: 143 lbs.
o BMI: 27.9 kg/m2
A BMI of 25.0-29.9 signifies her as overweight. A
normal BMI is 18.5-24.9.
HEENT:
Head and neck symmetric with no lumps, lesions, or tenderness.
No drooping of the face or eyelids. Neck moves freely with no
pain. Thyroid normal with no palpable nodules. Conjunctivae
clear and sclera white. PERRLA. Nose symmetric with no
deformities. Mouth mucosa and gingivae pink with no masses.
Moist membranes noted. Tongue smooth and pink and midline
with no lesions. No lymphadenopathy.
Cardiovascular:
No visible pulsation. Apical pulse palpated over the fifth
intercostal space at the midclavicular line with no thrill noted.
Heart rate 68, with regular rhythm, blood pressure 127/88.
Normal S1 and S2 present, no murmurs, rubs or gallops noted.
No JVD or carotid bruits. No edema or visible varicose veins in
lower extremities.
Respiratory:
AP:L ration 2:1. Respiratory rate 16 and nonlabored. Trachea
midline with no masses, lesions, or tenderness. Thoracic
expansion and tactile fremitus equal on both sides. Bilateral
breath sounds CTA, no adventitious breath sounds noted.
Percussion reveals resonance of all lung fields.
Gastrointestinal:
Abdomen round and symmetric. Bowel sounds active in all four
quadrants with no bruits heard. Tympany in all four quadrants.
No CVA tenderness. Soft to palpation with no masses or
tenderness. Deep palpation with no masses noted. Low,
transverse abdominal incision scar is well healed.
Genitourinary:
No lesions, ulcerations, or masses noted on external genitalia,
perineum, or rectum. Hair is evenly distributed throughout. The
clitoris is midline, approximately 1 cm in length, smooth, without
lesions, ulcerations or masses. The urethral orfice is midline,
pink, smooth and patent. No urine leakage with cough. The
vaginal opening is pink and round, with no visible bruising, tears,
lesions, ulcerations or masses. No vaginal discharge. Upon
examination with speculum, parous cervix appears intact, pink,
moist, round and centrally positioned with a small opening in the
center. No discoloration, ulcerations, lacerations, indurations or
masses visualized. Endometrial biopsy consent obtained and
procedure preformed, with adequate amount of tissue obtained.
Uterine sound measurement approximately 8 cm. Patient
tolerated the procedure well. Bimanual palpation revealed a firm,
smooth, parous cervix and retroverted uterus. No pain or
tenderness with palpation of the cervix, fornices, uterus, and
ovaries. No masses, nodules, or bulges noted with bimanual
palpation. Rectovaginal exam deferred. No visible hemorrhoids.
Integument/ lymphatic:
Skin intact, pink in color, warm to touch, smooth and even with
no rashes or bruising. No suspicious looking lesions present. Hair
is evenly distributed throughout on the head. No pest
inhabitation. Nail beds clean with no clubbing or deformities. No
lymphadenopathy noted.
Neurologic:
Alert and oriented, no focal deficits, motor strength normal in
upper and lower extremities, sensory exam intact. No
documented history of seizures or headaches.
Psychiatric:
Cooperative. Appropriate mood and affect, normal judgment.
Hematologic/ lymphatic/ immunologic:
No lymphadenopathy. No bruising.
Diagnostic Testing:
Differential Diagnoses:
Definitive Diagnoses:
Plan (P):
Follow-up: The office will call the patient with the results of
endometrial biopsy, and if warranted, bring her in earlier to
discuss surgical treatment options. Otherwise, office visit one
week after U/S (8 weeks from now) to review results (with
regards to ovarian cysts and endometrial thickening re-
evaluation) and discuss period regularity with progesterone
therapy.
Youngkin, E.Q. & Davis, M.S. (2004). Womens health: A primary care
clinical guide, (3rd ed.). Upper Saddle River, NJ: Pearson.