Obstetrics / Gynecology
Sample Name: First Pap smear.
Description: First Pap smear, complaining of irregular periods. - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: The patient comes for her first Pap smear, complaining of irregular periods.
HISTORY OF PRESENT ILLNESS: The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods. She notes that her periods are out of weck. She says that she has cramping and pain before her period starts. Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks. She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed. The cramping is worse. She said her flow has increased. She has to change her pad every half to one hour and uses a super tampon sometimes. She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad. She also notes that her headaches have been worsening a little bit. She has had quite a bit of stress. She had a headache on Wednesday again after having had one on the weekend. She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them. She avoids caffeine. She only eats chocolate when she is near her period and she usually drinks one can of cola a day.
SOCIAL HISTORY: She is a nonsmoker. She is not sexually active.
FAMILY HISTORY: Mother has hypertension, depression. Father has had renal cysts and sometimes some stomach problems. Both of her parents have problems with their knees.
REVIEW OF SYSTEMS: Patient denies headache or trauma. No blurred or double vision. Hearing is fine, no tinnitus or infection. Infrequent sore throat, no hoarseness or cough.
HEENT: See HPI.
Neck: No stiffness, pain or swelling.
Respiratory: No shortness of breath, cough or hemoptysis. She is a nonsmoker.
Cardiovascular: No chest pain, ankle edema, palpitations or hypertension.
GI: No nausea, vomiting, diarrhea, constipation, melena or jaundice.
Locomotor: No weakness, joint pain, tremor or swelling.
GYN: See HPI.
Integumentary: Patient performs self-breast examinations and denies any breast masses or nipple discharge. No recent skin or hair changes.
Neuropsychiatric: Denies depression, anxiety, tearfulness or suicidal thought.
VITALS: Height 64.5 inches. Weight: 162 pounds. Blood pressure 104/72. Pulse: 72. Respirations: 16. LMP: 08/21/04. Age: 19.
HEENT: Head is normocephalic. Eyes: EOMs intact. PERRLA. Conjunctiva clear. Fundi: Discs flat, cups normal. No AV nicking, hemorrhage or exudate. Ears: TMs intact. Mouth: No lesion. Throat: No inflammation.
Neck: Full range of motion. No lymphadenopathy or thyromegaly.
Heart: Normal sinus rhythm, no murmur.
Integumentary: Breasts are without masses, tenderness, nipple retraction or discharge. Reviewed self-breast examination. No axillary nodes are palpable.
Abdomen: Soft. Liver, spleen, and kidneys are not palpable. No masses felt, nontender. Femoral pulses strong and equal.
Back: No CVA or spinal tenderness. No deformity noted.
Pelvic: BUS negative. Vaginal mucosa pink, scanty discharge. Cervix without lesion. Pap was taken. Uterus normal size. Adnexa: No masses. She does have some pain on palpation of the uterus.
Rectal: Good sphincter tone. No masses. Stool is guaiac negative.
Extremities: No edema. Pulses strong and equal. Reflexes are intact.
Rectal: No mass.
PLAN: We will evaluate with a CBC, urinalysis and culture, and TSH. The patient has what she describes as migraine headaches of a new onset. Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram. We will evaluate with a CT scan of the brain with and without contrast. We will try Anaprox DS one every 12 hours for the headache. At this point, she could also use that for menstrual cramping. Prescription written for 20 tablets. If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow. The lab x-ray and urinalysis results will be reported to her as soon as they are available.
Keywords: obstetrics / gynecology, menorrhagia, pelvic pain, dysmenorrhea, pap smear, menstrual cramping, breast examinations, irregular periods, periods, menstrual, uterus, urinalysis, irregular, pelvic, cramping, headaches,