Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Complete Physical - Female

Description: An 18-year-old white female who presents for complete physical, Pap, and breast exam.
(Medical Transcription Sample Report)


SUBJECTIVE: This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college. She denies any problems at this time. Her last Pap smear was 06/25/2003 and was normal. She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time. We did discuss that she may have increased episodes of breakthrough bleeding.

PAST MEDICAL HISTORY: Fever blisters and allergic rhinitis.

MEDICATIONS: Allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and Ortho-Tri-Cyclen.

ALLERGIES: None.

SOCIAL HISTORY: Denies tobacco or drug use, rare alcohol use. She is sexually active and has had one partner.

FAMILY HISTORY: Positive for rheumatoid arthritis.

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

OBJECTIVE:
Vital Signs: Height 5 feet 6 inches. Weight 153 pounds. Blood pressure 106/72. Pulse 68. Respirations 12. Temperature 97.5. Last menstrual period 05/30/2004.
General: She is a well-developed, well-nourished white female in no acute distress.
HEENT: Tympanic membranes unremarkable. Oropharynx nonerythematous. Pupils equal, round, and reactive to light. Extraocular muscles intact.
Neck: Supple. No lymphadenopathy and no thyromegaly.
Chest: Clear to auscultation bilaterally.
CV: Regular rate and rhythm without murmur.
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. Normal vaginal rugation. No cervical lesions. No cervical motion tenderness. No adnexal tenderness or masses palpated.
Extremities: No cyanosis, clubbing, or edema.
Neurologic: 2+/4 DTRs in all extremities. 5/5 motor strength in all extremities. Negative Romberg.
Musculoskeletal: No abnormalities or laxity noted in any of her joints.

ASSESSMENT/PLAN:
1. Complete physical, Pap, and breast exam completed.
2. School physical form completed and returned to the patient.
3. Hepatitis B second injection will be given today.
4. Contraceptive surveillance. We will put patient to Seasonale to start at the end of this cycle a pill.
5. Allergic rhinitis. Prescription was given for Allegra 180 mg q.d. #30 carrying refills for her to take with her school Cowley County Community College.
6. Insomnia. Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school. She will follow up as needed.

Keywords: obstetrics / gynecology, complete physical, contraceptive surveillance, ortho-tri-cyclen, pap, pap smear, allergic rhinitis, breast exam, female genitalia, nipple discharge, ortho tri cyclen, tri cyclen, breast, physical,