Appointment for WWE – new patient. 99386
Does it support an extra office visit? Please see the doc below
HISTORY:
44 year old female c/o having malodor clear discharge since IUD Insertion.
Also c/o LLQ pain prior to having kids. Patient had colonoscopy done benign. Pain went away during pregnancy. Don’t know if she had pelvic ultrasound or not.
*
Location occasional back pain. Gained 30 pounds over the past 1 year.
Quality pressure like.
Severity 5/10 pain scale. There most of the time.
Duration more than years now.
TIming not related periods.
*Associated signs/Syptoms heavy period prior to IUD
*pt reports to have IUD Mirena insertion about 3 years ago. Patient used to have dark heavy periods with clots. All her sisters had this problems. IUD helped with pain.
no pain with intercourse. Patient’s husband had vasectomy and IUD Mirena for contraceptions.
Patient does leak urine when coughing or sneezing. Last 2 pregnancies, her uterus dropped. She has to cross her legs whenever she cough or sneeze or laugh. Feel like getting worse.
*Her last papsmear was 3-4 years. Her last mammogram was 3-4 years.
Patient works as: office manager for court recording agency.
*Cesarean Section x2 (4 year old daughter and 6 year old son).
*SOCIAL HISTORY: not smoked. She reports that she does not drink alcohol and denies used illicit drugs.
*Depression screening:
During the last month, patient denies any feeling down, depressed, or hopeless. Patient Report normal interest and pleasure in daily activities. Patient denies any suicidal ideation or thought of harming anyone.
*MEDICAL HISTORY:
Chronic LLQ pain *
Hernia, inguinal, bilateral *
SURGICAL HISTORY:
AUGMENTATION OF BREAST * 1996
BASSINI REPAIR OF INGUINAL HERNIA * *
* x2 bilaterally
CESAREAN DELIVERY ONLY * *
* x2
FAMILY HISTORY:
Stroke Mother 79
Cancer Father 60
* prostate cancer. died from it.
REVIEW OF SYSTEMS:. General: No weight change, generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Breast: No noted lumps, no tenderness, no swelling, no nipple discharge.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia. Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PHYSICAL:
*
LMP:
Patient’s last menstrual period was 12/20/2018.
*
Vitals:
BP: 130/73 | Pulse: 81 | Temp: 97.3 °F (36.3 °C) | Resp: (not recorded) | Height: 160 cm (5′ 3") | Weight: 72.6 kg (160 lb) | Body mass index is 28.34 kg/m².Body mass index is 28.34 kg/m².
*
PHYSICAL EXAM:
Awake, alert and oriented to person, place and time.
Psychiatric: alert, does not appeared depression, well groomed, good eye contact
ENT: Head normal configuration & texture. Nose normal color, no discharge. Teeth present and in good dentition,
Eyes: PERL, normal eye contact.
Neck and lymphatic and endocrine: active range of motion, thyroid non palpable lesions, normal size and consistency,
Breast and Skin: inspection normal size, symmetrical, nipples symmetrical and everted, no masses palpated and no discharge, no palpable enlarged lymph node supracervical and under axillary areas,
*Cardiovascular system: Thorax symmetrical expansion with respiration, RRR
Gastrointestinal: normal bowel sounds and Normal Bruits, no tenderness and masses with superficial and deep palpation,
Respiratory: clear lung sound bilaterally
*Musculoskeletal: normal range of motion, normal strength of upper and lower extremities. No tenderness noted in the lower back bilaterally
lower extremities showed Normal ranges of motion,dtr 2/4 patella bilaterally.
*Genitourinary: Normal external genitalia of labia, clitoris, urethral orifice, introitus.
3rd degree prolapse anteriorly, 2nd degree uterine prolapse.
External hemorhoid.
ASSESSMENT/PLAN
*1. Chronic pelvic pain in female
– US PELVIS W/ TRANSVAGINAL AND DOPPLER; Future
*2. Encounter for annual routine gynecological examination
– THINPREP PAP W IMAGER AND HPV RNA, HIGH RISK, E6/E7, TMA; Future
*3. Breast cancer screening
– SCREENING MAMMO BILAT DIGI W/CAD; Future
*4. Cervical cancer screening
– THINPREP PAP W IMAGER AND HPV RNA, HIGH RISK, E6/E7, TMA; Future
*5. BV (bacterial vaginosis)
– metroNIDAZOLE (FLAGYL) 500 mg Tablet; Take 1 tablet by mouth every 12 hours for 7 days. Dispense: 14 tablet; Refill: 0
*6. Urinary, incontinence, stress female
*7. Grade I hemorrhoids
– hydroCORTisone (ANUSOL-HC) 25 mg Suppository; Unwrap and insert 1 suppository rectally 2 times a day. Dispense: 60 suppository; Refill: 3
kegal, frequent intercourse, consider surgery dependent on pelvic ultrasound.
*PATIENT WILL FOLLOW UP WITH GI AND DR. ALEXANDRA.
*HIGH phq 8-DENIES SUICIDAL.
*NEED ULTRASOUND FIRST, IF PAIN PERSISTED CONSIDER DIAGNOSTIC LAPAROSCOPY