Andrea, a 43-year-old G4P4 premenopausal woman, returns to your office after the results of her PAP smear indicate a concern.
Identifying data: Ms. A is a 43 y/o Caucasian female.
Referral: None
Source: Patient
Reliability: Seems reliable
Allergies: NKA
Subjective
CC: Follow up Pap smear result
HPI:
Andrea, a 43-year-old G4P4 premenopausal woman, returns to your office after the results of her PAP smear indicate a concern, the test was done during the routine check up. She reports her last menstrual period was 2weeks prior to the visit. Her cycles usually involve of 1-2 days of moderate bleeding in which one tampon last a few hours, followed by 2-3 days of light bleeding and spotting in which a tampon or pad …show more content…
INTEG: No skin rashes, lesions, ulcerations, or abnormalities. Reports “stretch marks” on breast and hips. HEENT: No complaints of headaches change in hearing, earache. Denies nasal congestion, bleeding, drainage or change in sense of smell. Denies sore throat, dysphagia or problems with tooth pain, bleeding gums, hoarseness, or dry mouth. BREAST: Denies breast tenderness, mass, or lesion. Denies nipple abnormality or discharge. Respiratory: Denies cough, SOB, hemoptysis, or pain upon inspiration or expiration. CV: Denies chest pain, high blood pressure, irregular pulse or the feeling of the heart racing or missing beats. GI: Denies nausea, vomiting, hematemesis, abdominal pain, change in bowel habits, or heartburn. GU: Denies vaginal pruritis, discharge, or tenderness. Denies dyspareunia or change in libido. Denies history of pregnancy or STD. Denies hematuria, dysuria or change in urinary frequency. See HPI for additional information. Musculoskeletal: Denies muscle pain, arm or leg weakness, joint swelling or arthritis. Neurologic: Denies syncope, seizures, disorientation, anxiety, inability to concentrate, or difficulty with balance. Endocrine: Denies current problems with heat or cold intolerance, sweating, polyuria, polydipsia, or polyphagia. Vascular: Denies current problems with leg cramping, leg swelling, claudication, or
Identifying data: Ms. A is a 43 y/o Caucasian female.
Referral: None
Source: Patient
Reliability: Seems reliable
Allergies: NKA
Subjective
CC: Follow up Pap smear result
HPI:
Andrea, a 43-year-old G4P4 premenopausal woman, returns to your office after the results of her PAP smear indicate a concern, the test was done during the routine check up. She reports her last menstrual period was 2weeks prior to the visit. Her cycles usually involve of 1-2 days of moderate bleeding in which one tampon last a few hours, followed by 2-3 days of light bleeding and spotting in which a tampon or pad …show more content…
INTEG: No skin rashes, lesions, ulcerations, or abnormalities. Reports “stretch marks” on breast and hips. HEENT: No complaints of headaches change in hearing, earache. Denies nasal congestion, bleeding, drainage or change in sense of smell. Denies sore throat, dysphagia or problems with tooth pain, bleeding gums, hoarseness, or dry mouth. BREAST: Denies breast tenderness, mass, or lesion. Denies nipple abnormality or discharge. Respiratory: Denies cough, SOB, hemoptysis, or pain upon inspiration or expiration. CV: Denies chest pain, high blood pressure, irregular pulse or the feeling of the heart racing or missing beats. GI: Denies nausea, vomiting, hematemesis, abdominal pain, change in bowel habits, or heartburn. GU: Denies vaginal pruritis, discharge, or tenderness. Denies dyspareunia or change in libido. Denies history of pregnancy or STD. Denies hematuria, dysuria or change in urinary frequency. See HPI for additional information. Musculoskeletal: Denies muscle pain, arm or leg weakness, joint swelling or arthritis. Neurologic: Denies syncope, seizures, disorientation, anxiety, inability to concentrate, or difficulty with balance. Endocrine: Denies current problems with heat or cold intolerance, sweating, polyuria, polydipsia, or polyphagia. Vascular: Denies current problems with leg cramping, leg swelling, claudication, or