Daniel DeMarco              Focused H&P #8              OB/GYN

Chief Complaint: “I am here for my regular Woman’s well-visit.”

 

History of Present Illness:

LE is a 51yo with OBHx 3x uncomplicated C/S. Her LMP was 4/2/2019, though she complains that her periods sometimes occur every two to three months. She uses condoms for contraception, though denies use of any other forms of contraceptives or hormonal therapies. She cannot recall when her last PAP smear or Mammogram were performed, though they were normal per patient. Patient states she has not yet had a colonoscopy. Denies history of previous abnormal PAP smears, mammograms, STIs. Denies vaginal bleeding, vaginal fullness, incontinence, hot flashes, new or changing breast masses, nausea, vomiting, fever, chills, weight loss.

 

Obstetric History: 3x Uncomplicated C/S (1990 – due to arrest of descent, 1992, 1997)

Gynecologic History: None

PMH: HTN, HLD, PreDM, Thyroid Cancer, Hypothyroidism

Medications: Metoprolol tartrate 50mg PO bid, Atorvastatin 40mg PO qd, Synthroid 75mcg PO qd

PSH: Thyroidectomy (2004), Tonsillectomy (1984)

Allergies: NKDA

Family History: None

Social History: Never smoker. Social EtOH use. No illicit drug use. Admits sexual activity with one male partner.

 

Review of Systems:

General : Denies fever, chills, night sweats, loss of appetite, weight loss, weight gain, weakness, fatigue

Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations,

pigmentations, moles, rashes, pruritus, change in hair distribution

Head : Denies trauma, unconsciousness, coma, fracture, vertigo, headache

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation, vision changes

Ears : Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses : Denies discharge, epistaxis, rhinorrhea, congestion

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes,

dentures

Neck : Denies lumps, swelling, stiffness, decreased range of motion

Breast : Denies lumps, nipple discharge, pain

Respiratory : Denies dyspnea, shortness of breath, wheezing, cough, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular : Denies palpitations, irregular heartbeat, edema, syncope, chest pain, known heart murmur

Gastrointestinal : Denies abdominal pain, vomiting, change in appetite, intolerance to specific foods, nausea, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool

Genitourinary : Denies vaginal bleeding, dyspareunia, change in frequency, urgency, hesitancy, dribbling, nocturia, polyuria, oliguria, dysuria, change in urine color, incontinence, flank pain

Musculoskeletal : Denies joint pain, deformity, swelling, redness, arthritis

Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, color change, edema

Hematologic : Denies anemia, easy bruising/bleeding, lymph node enlargement, history of

DVT/PE

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia,

dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss,

asymmetric weakness

Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual

activities, suicidal ideation, anxiety

 

Physical Exam:

Vital Signs:

BP: 145/90

Pulse: 82 bpm

RR: 16 breaths/min

Temp: 36.8C

SpO2: 100%RA

Ht: 54in.

Wt: 79.8kg

 

General Survey: Patient lying comfortably in bed. No apparent distress.

Skin: No petechiae, masses, lesions. Warm, moist.

Hair: Average quantity and distribution.

Breast: Symmetrical and without observable or palpable masses. Bilateral nipples without discharge. No axillary, infraclavicular, or supraclavicular adenopathy bilaterally.

Female Genital Exam: No inguinal adenopathy. External genitalia without erythema or lesions. Vaginal mucosa pink. Cervix pink and without discharge. Uterus anterior, midline, smooth, and not enlarged. No cervical motion tenderness or adnexal tenderness.

 

Labs:

 

Normal UA

 

Assessment/Plan:

LE is a perimenopausal 51yo with LMP 4/2/2019 here today for annual GYN visit.

 

OB/GYN

#Annual GYN Visit

– PAP Smear with HPV Cotesting

– Gonorrhea/Chlamydia Cervical Swab

– Scheduled for Mammogram on 5/28/2019

– Referral for Colonoscopy given. Discussed Colon Cancer screening

– Perimenopause and Menopause education performed

– Discussed Breast Self-Awareness

 

Follow up for annual GYN visit in 1yr or sooner as clinically needed

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student