Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Physical Exam and Pap - 1
A white female presents for exam and Pap.
(Medical Transcription Sample Report)
This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap. Last Pap was a year ago and normal. LMP was 08/29/2004. Her cycles are usually regular, although that one came about a week early. Her husband has had a vasectomy. Overall, she is feeling well.
Health history form was reviewed. There has been no change in her personal history. She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again. Social history is unchanged.HEALTH HABITS:
She states that for a while she was really exercising regularly and eating lots of fruits and vegetables. Right now, she is not doing nearly as well. She has perhaps two dairy servings daily, trying to cut down. She is not exercising at all and fruit and vegetable intake varies. She is a nonsmoker. Last cholesterol was in 2003 and was normal. She had a mammogram which was normal recently. She is current on her tetanus update.REVIEW OF SYSTEMS:
HEENT: She feels as though she may have some allergies at night. Most of her symptoms occur then, not during the day. She will wake up with some congestion, sneezing, and then rhinorrhea. Currently, she uses Tylenol Sinus. Today, her symptoms are much better. We did have rain this morning.
Respiratory and CV: Negative.
GI: She tends to have a little gas which is worse when she is eating more fruits and vegetables. She had been somewhat constipated but that is better.
Dermatologic: She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint. It was very sensitive to water. It seems to be slowly improving.OBJECTIVE:
Vital Signs: Her weight was 154 pounds, which is down 2 pounds. Blood pressure 104/66.
General: She is a well-developed, well-nourished, pleasant white female in no distress.
Neck: Supple without adenopathy. No thyromegaly or nodules palpable.
Lungs: Clear to A&P.
Heart: Regular rate and rhythm without murmurs.
Breasts: Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.
Abdomen: Soft without organomegaly, masses, or tenderness.
Pelvic: Reveals no external lesions. The cervix is parous. Pap smear done. Uterus is anteverted and normal in size, shape, and consistency, and nontender. No adnexal enlargement.
Extremities: Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.ASSESSMENT:
1. Normal GYN exam.
2. Rhinitis, primarily in the mornings. Vasomotor versus allergic.
3. Eczematous dermatitis on right third finger.PLAN:
1. Discussed vasomotor rhinitis. I suggested she try Ayr Nasal saline gel. Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.
2. Exam with Pap annually.
3. Hydrocortisone cream to be applied to the area of eczematous dermatitis.
4. Discussed nutrition and exercise. I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.
consult - history and phy., pap, gyn exam, rhinitis, eczematous, dermatitis, fruits and vegetables, eczematous dermatitis, vasomotor,
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