Tuesday, March 29, 2005

DJR's sample transcriptions

SUBJECTIVE: The patient presents for follow up. She saw Dr.XXXX yesterday. She had a positive pregnancy test. She had some cramping on 3/22 but is doing fine now. Her last menstrual period was 12/18/04; however, she does have a history of irregualar menses. She just recently started having nausea and some breast tenderness about 3 to 4 weeks ago.

PAST MEDICAL HISTORY: Negative for chronic illnesses or operations.

ALLERGIES: None.

CURRENT MEDICATIONS: None

OBJECTIVE:

Vital signs: Blood pressure 110/70; temperature 98; pulse 68; respirations 19; weight 149 pounds; height 5 feet 3 inches.

Pelvic: Vulva: no lesions. Vagina: clear. Cervix: nulliparous, nonfriable, no cervical motion tenderness. Uterus: slightly enlarged and globular, nontender. Adnexa: no masses or tenderness.

ASSESSMENT: Growing pregnancy

PLAN: The patient was advised for starting prenatal multivitamins, Novonatal 1 tab p.o. daily, advised to avoid medicines or other substances. She will have pelvic ultrasound on 8th dating of the pregnancy. Schedule new OB appointment. Follow up p.r.n..

**************

SUBJECTIVE: The patient presents for refill on Ortho Tri-cyclen low. She is currently a pharmacy student back at University of Illinois, Chicago, and will be graduating in May. She will be getting married in June, hence, has recently started on Ortho Tri-cyclen low. She denies problems.

PAST MEDICAL HISTORY: Negative for chronic illnesses. She has a history of appendectomy.

ALLERGIES: None

CURRENT MEDICATIONS: Ortho Tri-cyclen low.

OBJECTIVE:

Vital signs: Blood pressure 100/60; temperature 98; pulse 56; respirations 19; weight 108 pounds; height 5 feet.

ASSESSMENT: Family planning.

PLAN: Questions were answered in regard to oral contraceptives. In particular the patient wanted to know how she can avoid menses at the time of her waning. I advised her to skip placebos in the pack that month, and just start the next pack. She will follow up p.r.n. and in July after her marriage so she can have her first Pap smear.
*********

SUBJECTIVE: The patient presents for the first time to our office for annual examination and Pap smear, and also wants to discuss birth control. Her last menstrual period was 3/1/05.

PAST MEDICAL HISTORY: Negative for chronic illnesses or operations.

ALLERGIES: None.

SOCIAL HISTORY: The patient is a nonsmoker.

FAMILY MEDICAL HISTORY: The father is alive and well. The mother has hypertension.

GYN HISTORY: Menarche at age 15, with regular cycles. Her last Pap smear was two years ago. She has history of Chlamydia approximately 2 to 3 years ago during her last pregnancy.

OB HISTORY: The patient is a gravida 6 para 6; all of pregnancies were normal with vaginal deliveries.

OBJECTIVE:

Vital signs: Blood pressure 110/70; temperature 98.2; pulse 76; respirations 19; weight 172 pounds; height 5 feet 2 1/2 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Extremities: Within normal limits.

ASSESSMENT:

  1. Stress incontinence.
  2. Family planning.
PLAN: Pap smear was done. The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. Also teaching was done and a handout was given regarding Kegel exercises as the patient was complaining of losing urine when she coughs or sneezes. I also answered questions in regard to birth control. The patient is very interested in IUD. She cannot use oral contraceptives of Depo-Provera because she has extensive varicose veins. Handouts were given in regard to IUD and other birth control methods. We will submit referral to determine her insurance coverage with this method. She will also screen today for gonorrhea and chlamydia. The patient is to call me in one week to check authorization for IUD. Follow up p.r.n. and yearly.
**********

SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was 3/24/05. There has been no change in her health status since examination one year ago except for recent treatment of pneumonia.

ALLERGIES: None.

CURRENT MEDICATIONS: None.

OBJECTIVE:

Vital signs: Blood pressure 120/70; temperature 96.8; pulse 72; respirations 20; weight 160 pounds; height 5 feet 1 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Rectum: No masses.

Extremities: Within normal limits.

ASSESSMENT: Normal well-woman examination.

PLAN: Paps smear was done. The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. Return to the clinic p.r.n. and yearly.
***********

SUBJECTIVE: The patient presents for annual examination and Paps smear and refill of Ortho Evra patch. Her last Pap smear was 11/20/02 and normal. Her last menstrual period was 3/21/05. She denies problems.

ALLERGIES: None.

CURRENT MEDICATIONS: Ortho Evra patch.

OBJECTIVE:

Vital signs: Blood pressure 110/68; weight 138 pounds.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: With small amount of menstrual blood. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender.. Adnexa: No masses or tenderness.

Extremities: Within normal limits.

ASSESSMENT:

  1. Normal well-woman examination.
  2. Family planning.
PLAN: Pap smear done. I reinforced multi-self breast examination. Ortho Evra patch refill was given. Return to the clinic p.r.n. and yearly. I stressed the importance of annual examination and Pap smear screening.
*****

SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was 3/09/05. She is complaining of vulvar and vaginal irritation and discharge. Her health status is unchanged since her last examination 12/08/03, except that after she was screened by this office and found to have elevated blood sugar. She was referred to Dr. XXX who advised her to go on a low-carbohydrate diet and also started her on oral medication for diabetes. The patient took the medications for a while and then stopped about 6 months ago. She has an appointment tomorrow with Dr. Echeverri for followup and will go in fasting so that she can have followup blood sugar studies done.

ALLERGIES: None.

CURRENT MEDICATIONS: None.

OBJECTIVE:

Vital signs: Blood pressure 112/74; temperature 99.6; pulse 96; respirations 16; weight 243 pounds; height 5 feet 8 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: With mild erythema, however, with no lesions. Vagina: Positive for frothy discharge. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Extremities: Within normal limits.

DIAGNOSTIC STUDIES: Wet mount shows positive clue cells.

ASSESSMENT:

  1. Bacterial vaginosis.
  2. Adult-onset diabetes/poor compliance with therapy.
PLAN: Pap smear was done. I reinforced multi-self breast examination, daily calcium needs, regular exercise and low-carbohydrate diet. I stressed the importance of the patient's good compliance with diet and therapy to avoid long-term complications, such as cardiovascular disease, renal disease, and eye problems. The patient agreed that she would follow up with Dr. XXX as scheduled. Metronidazole 500 mg #14 1 tab orally b.i.d. for 7 days. The patient was advised to take it after meals, and also to refrain from alcohol during treatment and up to 3 days after finishing. Teaching reinforced in regard to prevention of vaginal infections. Return to the clinic p.r.n. and yearly.
*******
SUBJECTIVE: The patient presents for annual examination and Paps smear. She denies problems. Her last menstrual period was approximately 1999.

PAST MEDICAL HISTORY: Significant for hypercholesterolemia.

CURRENT MEDICATIONS:

  1. Zantac 150 mg b.i.d.
  2. Lipitor and Gennin were discontinued recently after the patient was found to have anemia.
OBJECTIVE:

Vital signs: Blood pressure 90/50; temperature 97.8; pulse 64; respirations 16; weight 115 pounds; height 4 feet 11 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Rectum: No masses and heme-negative.

Extremities: : Within normal limits.

ASSESSMENT:

  1. Normal well-woman examination.
  2. Premature menopause.
PLAN: Pap smear was done.The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. I stressed the importance of the patient getting sufficient calcium in her diet, as with early menopause she is at a higher risk for osteoporosis changes. Return to the clinic p.r.n. and yearly.
******
SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was January 2005. Her menses continue to be kind of sporadic.The patient complains of recent episodes of feeling tired; otherwise, there is no change in has health status since her examination one year ago.She already has mammogram scheduled for next week.

OBJECTIVE:

Vital signs: Blood pressure 110/60; temperature 98; pulse 76; respirations 19; weight 174 pounds; height 5 feet 2 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Rectum: No masses.

Extremities: Within normal limits.

ASSESSMENT:

  1. Fatigue.
  2. Normal well-woman examination.
PLAN: Pap smear was done. The patient is to go to the laboratory in the morning fasting for comprehensive metabolic panel, lipid panel, CBC and TSH. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. I will call the patient with laboratory results. To follow up p.r.n. and yearly.
****
SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was 3/20/05. She denies problems. There is no change in her health status since examination one year ago.

ALLERGIES: PENICILLIN

CURRENT MEDICATIONS:

  1. Synthroid 125 mcg daily.
  2. Vitamin B12 1 tablet daily.
  3. Multivitamins occasionally.
OBJECTIVE:

Vital signs: Blood pressure 102/64; temperature 97.4; weight 122 1/2 pounds; height 5 feet 2 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Rectum: No masses.

Extremities: Within normal limits.

ASSESSMENT: Normal well-woman examination.

PLAN: Pap smear was done. The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. Return to the clinic p.r.n. and yearly.
********
SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was 3/22/05. She is currently under the care of infertility specialist as she has been trying to get pregnant for over a year. She was previously on [0:30]. She has now a full battery of tests, including bloodwork and hysterosalpingogram which were normal. Infertility specialist has advised her to have in vitro fertilization so she is doing all her annual screening tests before this is done, including her Pap smear and will also need a mammogram. She needs several prescriptions written for medications that she will take at least during that one month after the in vitro fertilization.

PAST MEDICAL HISTORY: Significant for hyperthyroidism.

ALLERGIES: None.

CURRENT MEDICATIONS: PTU 1 tab daily

OBJECTIVE:

Vital signs: Blood pressure 118/68; temperature 96.8; weight refused; height 5 feet 5 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Nulliparous, nonfriable, no cervical motion tenderness Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Extremities: Within normal limits.

ASSESSMENT: Normal well-woman examination.

PLAN: Pap smear was done. The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. The patient was given prescriptions for dexamethasone 0.5 mg 1 tab PO daily, doxycycline 100 mg 1 tab PO daily for 30 days, Vivelle transdermal patch 0.1 mg one patch thrice a week, and Medrol 8 mg #8 1 tab PO times 8 days. Return to the clinic p.r.n. and yearly.
*****

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