Papsmear week 4

Name:  WF

Date: 04/16/2019

Time: 1400

Age: 27

Sex: F

SUBJECTIVE

CC: 

“I am here for my papsmear”

HPI: 

Patient is a 27 year old WF that presents for annual gynecologic exam, denies any problems at this time, states she uses Nexplanon for contraception and denies any problems with this contraception. Patient has no significant medical history. Last pap x 2 years ago.

Medications:

Nexplanon Implant (Contraception)

PMH

Allergies: NKDA

Medication Intolerances: NONE

Chronic Illnesses/Major traumas

None

Hospitalizations/Surgeries

Tonsillectomy- age 17

Vaginal birth (twins) x 3 years ago

Family History

Mother- Living with hypertension

Father-Living with Hypertension

Social History

Lives with husband and twin daughters. Denies substance use/abuse, ETOH, tobacco, and marijuana use.

ROS

General

Denies weight change, fatigue, fever, chills, night sweats, energy level changes

Cardiovascular

Denies chest pain, palpitations, PND, orthopnea, edema

Skin

Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

Denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Eyes

Wears contacts, blurring, visual changes of any kind

Gastrointestinal

Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ears

Denies ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Denies urgency, frequency burning, change in color of urine.

In monogamous relationship with husband for the past 5 years. Denies history of STDS.

   Fe: last pap x 2 years ago, does not perform SBE.

Denies menstrual complaints, vaginal discharge.

Nose/Mouth/Throat

Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Musculoskeletal

Denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast

Denies SBE, lumps, bumps or changes

Neurological

Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Heme/Lymph/Endo

Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric

Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight   180     BMI 29.1

Temp 98.9

BP 130/86

Height 5’6

Pulse 78

Resp 18

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen overweight; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. 

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and multiparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable.

Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masse, sphincter tone is firm

Specimen collected and sent to lab for examination.

Patient tolerated procedure well.

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean pants and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Wet prep – pending

Pap Smear- Pending

Special Tests

 N/A

 Diagnosis

 Differential Diagnoses and Rationale

· 1- Screening for malignant neoplasm of cervix

Z12.4: Encounter for screening for malignant neoplasm of cervix

Rationale: Patients that fall within this patient’s age range should have a pap smear to screen for cervical cancer every 5 years if most recent pap was noted to be normal (Schuiling & Likis, 2016).

Diagnosis

o 1- Screening for malignant neoplasm of cervix

Z12.4: Encounter for screening for malignant neoplasm of cervix

Rationale: Patients that fall within this patient’s age range should have a pap smear to screen for cervical cancer every 5 years if most recent pap was noted to be normal (Schuiling & Likis, 2016).

Reference

Schuiling, K. D. & Likis, F. E. (2016). Women’s Gynecologic Health (3rd ed.). Sudbury, MA: Jones & Bartlett. Retrieved from: https://digitalbookshelf.southuniversity.edu/#/books/9781284124637/cfi/6/64!/4/2/6/26/12/6/4@0:0

Plan/Therapeutics

· Plan: 

· Further testing: No further testing currently. The need for further testing will be evaluated once the patient’s laboratory results are in.

· Medication

No medications at this time.

· Education

Patient educated on performing SBE at home. Instructed that she will be called to go over lab results.

Non-medication treatments

Instructed to return to the office in one year for annual exam, or sooner, if needed.

 Evaluation of patient encounter ( PLEASE COMPLETE)