Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Well-woman checkup
Description: Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: The patient comes for her well-woman checkup.
HISTORY OF PRESENT ILLNESS: She feels well. She has had no real problems. She has not had any vaginal bleeding. She had a hysterectomy. She has done fairly well from that time till now. She feels like she is doing pretty well. She remains sexually active occasionally. She has not had any urinary symptoms. No irregular vaginal bleeding. She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well. She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves. She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep. She does not report any swelling or inflammation, or pain. She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.
MEDICATIONS: Tetracycline 250 mg daily, Inderal LA 80 mg every other day.
PAST MEDICAL HISTORY: She had rosacea. She also has problems with “tremors” and for that she takes Inderal LA. Hysterectomy in the past.
SOCIAL HISTORY: She drinks four cups of coffee a day. No soda. No chocolate. She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much. They walk every evening for one hour.
FAMILY HISTORY: Her mother is in a nursing home; she had a stroke. Her father died at age 86 in January 2004 of congestive heart failure. She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.
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.
Neck: No stiffness, pain, or swelling.
Respiratory: No shortness of breath, cough, or hemoptysis.
Cardiovascular: No chest pain, ankle edema, palpitations, or hypertension.
GI: No nausea, vomiting, diarrhea, constipation, melena, or jaundice.
GU: No dysuria, frequency, urgency, or stress incontinence.
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.
VITAL SIGNS: Height: 62 inches. Weight: 134 pounds. Blood pressure: 116/74. Pulse: 60. Respirations: 12. Age 59.
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. She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her. She wears glasses.
Neck: Full range of motion. No lymphadenopathy or thyromegaly.
Chest: Clear to auscultation and percussion.
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 atrophic. Cervix and uterus are absent. No Pap was taken. No adnexal masses.
Rectal: Good sphincter tone. No masses. Stool guaiac negative.
Extremities: No edema. Pulses strong and equal. Reflexes are intact. Romberg and Babinski are negative. She is oriented x 3. Gait is normal.
ASSESSMENT: Middle-aged woman, status post hysterectomy, recent urinary tract infection.
PLAN: We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture. I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today. We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available. Continue same meds. Recheck annually unless she has problems sooner.
Keywords: consult - history and phy., well-woman checkup, hysterectomy, urinary tract infection, middle aged woman, status post hysterectomy, vaginal bleeding, breast examinations, infection, woman, urinary,