CHIEF COMPLAINT: Pap smear, breast exam.
SUBJECTIVE: The patient is a (XX)-year-old female, a patient of Dr. John Doe, who comes in today for her annual Pap smear and breast examination.
We ordered a bone density for her in MM/YYYY that showed worsening of osteopenia but no osteoporosis. The patient has not been taking calcium or vitamin D, but she states that she is planning to do so next.
GYNECOLOGIC HISTORY: LMP was over 15 years ago. No vaginal bleeding since. The patient is a G2, P1, 1 induced abortion, 1 C-section. The patient is sexually active with one partner and suffers from vaginal dryness, which is relatively well controlled with K-Y jelly. She has a remote history of gonorrhea, which was treated. Last Pap smear was in MM/YYYY and was normal. No history of abnormal Paps. She does regular breast exams. Last mammogram was over a year ago and was normal. No history of abnormal mammograms. Bone density, MM/DD/YYYY, osteopenia in the upper lumbar spine with worsening T score from 1.7 to 1.9 since August XXXX. Normal bone density in the left total hip.
OBJECTIVE:
Vital Signs: Blood pressure 142/98, heart rate 86, weight 146 pounds.
General: Alert, oriented, not in acute distress, pleasant, talkative Hispanic female.
Breasts: Symmetrical. No palpable masses. No nipple discharge. No skin changes, retractions or dimpling. No axillary lymphadenopathy.
Pelvic: Cervix is tilted to the patient’s left. No abnormal discharge. No cervical or vaginal lesions. No stenosis. Bimanual exam reveals no adnexal or uterine enlargement. No cervical motion tenderness.
Rectal: Good sphincteric tone. No hemorrhoids. No palpable masses. Stool is guaiac negative.
ASSESSMENT AND PLAN:
1. Healthcare maintenance: Pap smear obtained. Schedule a mammogram. Bone density in XXXX. We advised calcium with vitamin D twice daily as well as weightbearing exercises and smoking cessation. Continue self-breast exams.
2. Hypertension: Check blood pressures at home and follow up with Dr. John Doe for persistently elevated readings.
