Medical Specialty:
Obstetrics / Gynecology

Sample Name: Physical Exam and Pap -2

Description: A white female who presents for complete physical, Pap and breast exam.
(Medical Transcription Sample Report)

SUBJECTIVE: The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam. Her last Pap smear was 05/02/2002. Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest. Has awakened her at night on occasion and only last about 15 to 20 minutes. Denies nausea, vomiting, diaphoresis or shortness of breath with it. This has not happened in almost two months. She had a normal EKG one year ago. Otherwise, has been doing quite well. Did quite well with her foot surgery with Dr. Clayton.

PAST MEDICAL HISTORY: Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.

MEDICATIONS: Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.


SOCIAL HISTORY: She is married. Denies tobacco, alcohol and drug use. She is not employed outside the home.

FAMILY HISTORY: Unremarkable.

REVIEW OF SYSTEMS: HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.

Vital Signs: Weight 146. Blood pressure 100/64. Pulse 80. Respirations 16. Temperature 97.7.
General: She is a well-developed, well-nourished white female in no acute distress.
HEENT: Grossly within normal limits.
Neck: Supple. No lymphadenopathy. No thyromegaly.
Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm.
Abdomen: Positive bowel sounds, soft and nontender. No hepatosplenomegaly.
Breasts: No nipple discharge. No lumps or masses palpated. No dimpling of the skin. No axillary lymph nodes palpated. Self-breast exam discussed and encouraged.
Pelvic: Normal female genitalia. Atrophic vaginal mucosa. No cervical lesions. No cervical motion tenderness. No adnexal tenderness or masses palpated.
Rectal: Normal sphincter tone. No stool present in the vault. No rectal masses palpated.
Extremities: No cyanosis, clubbing or edema. She does have obvious rheumatoid arthritis of her hands.
Neurologic: Grossly intact.

1. Chest pain. The patient will evaluate when it happens next; what she has been eating, what activities she has been performing. She had normal ECG one year ago. In fact this does not sound cardiac in nature. We will not do further cardiac workup at this time. Did discuss with her she may be having some GI reflux type symptoms.
2. Hypothyroidism. We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.
3. Rheumatoid arthritis. Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.
4. Osteoporosis. It is time for her to have a repeat DEXA at this time and that will be scheduled.
5. Health care maintenance, Pap smear was obtained today. The patient will be scheduled for mammogram.

Keywords: obstetrics / gynecology, complete physical, pap smear, breast exam, rheumatoid arthritis, masses palpated, smear, lymphadenopathy, chest, cervical, tenderness, rectal, cardiac, physical, rheumatoid, arthritis, masses, breast, palpated, pap,