HISTORY OF PRESENT ILLNESS: This is a pleasant (XX)-year-old gravida 2, para 2, postmenopausal female who presents today for a routine GYN exam. She was last seen by Dr. John Doe on MM/DD/YYYY. Pap smear at that time was negative for malignancy. The patient has no current GYN complaints and denies any postmenopausal bleeding. No changes to bladder or bowel pattern. The patient denies abdominal pain or bloating.
PAST MEDICAL/SURGICAL HISTORY:
1. Postsurgical hypothyroidism.
2. Hypertension.
3. Hyperlipidemia.
4. Depression.
5. Osteoarthritis.
MEDICATIONS: Lisinopril, Lipitor, Synthroid, Allegra, buspirone, Zoloft, Xanax p.r.n., Flonase p.r.n., baby aspirin, multivitamin, calcium with vitamin D twice daily, vitamin C, vitamin E, glucosamine/chondroitin, magnesium, Benadryl, CoQ10, and flaxseed oil.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient is divorced. The patient denies domestic safety concerns. The patient is a nonsmoker. No alcohol abuse.
FAMILY HISTORY: Negative for breast, ovarian and colon cancer.
REVIEW OF SYSTEMS: Most recent mammogram was negative for malignancy. Most recent bone mineral density was read as low-normal mineralization of the hip and normal bone density of the spine. The patient is followed by Dr. Jane Doe for her thyroid disease and is scheduled to see her this month.
PHYSICAL EXAMINATION: General: This is a well-appearing (XX)-year-old, in no acute distress. Vital Signs: Height 5 feet 5 inches, weight 210 pounds, blood pressure 124/88, pain score 0/10. Lymph node survey: Unremarkable. No supraclavicular, axillary or inguinal lymph nodes palpable. Breasts: Breast examination in the supine position is negative for masses, lumps and nipple discharge. Abdomen: Soft, nontender to palpation. No hepatosplenomegaly or masses palpated. Pelvic: Pelvic exam revealed normal female external genitalia, urethra, and vagina with skin intact and no lesions noted. Internal exam revealed vaginal vault free of bleeding and discharge. Cervix is well visualized. ThinPrep Pap was obtained along with HPV DNA test. Bimanual Exam: No masses and no tenderness. Adnexa negative. Rectovaginal Exam: No masses, no tenderness.
ASSESSMENT AND PLAN:
1. Normal postmenopausal gynecologic exam. We will notify the patient of her Pap and HPV DNA results and recommend one-year followup with Dr. John Doe unless otherwise indicated.
2. Health maintenance. Encouraged continued increase in cardiovascular and weightbearing exercise, continued calcium supplementation, and monthly self-breast exams.
Sample #2
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old G0 postmenopausal female who presents today for a routine GYN exam. The patient was last seen here in our department in November and had a Pap that was negative. The patient is postmenopausal now with no complaints, was on hormone replacement therapy for approximately 5 years, and is off that now for the past 4 years. No complaints of any postmenopausal vaginal bleeding. No discharge, itching, burning. No abdominopelvic pain or any change in her elimination pattern. The patient has had no change in her medical or surgical history since her last visit here. She did specifically quit smoking in (XXXX), which she is quite happy with.
PAST MEDICAL/SURGICAL HISTORY: Notable for hypercholesterolemia, left shoulder history, cortisone injection, and history of left breast biopsy x2, both negative.
MEDICATIONS: Include Lipitor as well as vitamins.
ALLERGIES: None.
FAMILY HISTORY: No gynecological malignancies known.
SOCIAL HISTORY: The patient is a previous smoker, quit in (XXXX). Negative alcohol abuse. Positive for exercise with walking and jogging and positive for calcium-rich foods, including milk and yogurt.
PHYSICAL EXAMINATION: General: The patient is a pleasant (XX)-year-old female in no acute distress. Vital Signs: Height is 5 feet 5 inches. Weight is 170 pounds. Blood pressure 100/72. She has pain 0 on a scale of 1 to 10. Lymph node survey: Unremarkable. No supraclavicular, axillary or inguinal nodes palpated. Breasts: Exam in the supine position with no masses, no lumps, and no nipple discharge. Abdomen: Soft, nontender to palpation with no hepatosplenomegaly or masses palpated. Pelvic: Examination revealed normal female external genitalia, urethra and vagina with her skin intact and no lesions noted. Internal Examination: Vaginal speculum was used. Vaginal vault was free of any bleeding or discharge. Atrophic changes are present. Cervix: Well visualized, small, smooth, no CMT. Pap was obtained as well as Digene for human papillomavirus DNA. Bimanual exam revealed no masses, no tenderness. Adnexa nonpalpable. Rectovaginal Examination: No masses, no tenderness.
ASSESSMENT AND PLAN:
1. Annual gynecological examination: Pap was obtained today as well as Digene for human papillomavirus deoxyribonucleic acid. We discussed with the patient the current guidelines regarding Pap and deoxyribonucleic acid testing that if both results are negative, she should still follow up annually for a breast and pelvic exam, but she would not need a Pap for 3 years.
2. Health maintenance: Encouraged annual mammogram surveillance. The patient is due next month. We encouraged annual screening, monthly breast self-examinations, regular exercise and vitamins, calcium 1500 mg a day, vitamin D in divided doses. All of her questions were answered today. We will send her a note with the results. Her bone density in November revealed some mild osteopenia. Encouraged the patient to try to be consistent with her calcium. Recommended she could try some Viactiv chews if she is unable to tolerate the Caltrate as well as the calcium-rich foods. We will repeat a bone density next year.
