![]() Positive for exercise with walking and jogging and positive for calcium-rich foods, including milk and yogurt. SOCIAL HISTORY: The patient is a previous smoker, quit in (XXXX). MEDICATIONS: Include Lipitor as well as vitamins.įAMILY HISTORY: No gynecological malignancies known. PAST MEDICAL/SURGICAL HISTORY: Notable for hypercholesterolemia, left shoulder history, cortisone injection, and history of left breast biopsy x2, both negative. She did specifically quit smoking in (XXXX), which she is quite happy with. The patient has had no change in her medical or surgical history since her last visit here. No abdominopelvic pain or any change in her elimination pattern. No complaints of any postmenopausal vaginal bleeding. The patient is postmenopausal now with no complaints, was on hormone replacement therapy for approximately 5 years, and is off that now for the past 4 years. The patient was last seen here in our department in November and had a Pap that was negative. HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old G0 postmenopausal female who presents today for a routine GYN exam. ![]() Encouraged continued increase in cardiovascular and weightbearing exercise, continued calcium supplementation, and monthly self-breast exams. We will notify the patient of her Pap and HPV DNA results and recommend one-year followup with Dr. Rectovaginal Exam: No masses, no tenderness.ġ. ![]() Bimanual Exam: No masses and no tenderness. ThinPrep Pap was obtained along with HPV DNA test. Internal exam revealed vaginal vault free of bleeding and discharge. Pelvic: Pelvic exam revealed normal female external genitalia, urethra, and vagina with skin intact and no lesions noted. No hepatosplenomegaly or masses palpated. Breasts: Breast examination in the supine position is negative for masses, lumps and nipple discharge. No supraclavicular, axillary or inguinal lymph nodes palpable. Vital Signs: Height 5 feet 5 inches, weight 210 pounds, blood pressure 124/88, pain score 0/10. PHYSICAL EXAMINATION: General: This is a well-appearing (XX)-year-old, in no acute distress. Jane Doe for her thyroid disease and is scheduled to see her this month. Most recent bone mineral density was read as low-normal mineralization of the hip and normal bone density of the spine. REVIEW OF SYSTEMS: Most recent mammogram was negative for malignancy. No alcohol abuse.įAMILY HISTORY: Negative for breast, ovarian and colon cancer. The patient denies domestic safety concerns. MEDICATIONS: Lisinopril, Lipitor, Synthroid, Allegra, buspirone, Zoloft, Xanax p.r.n., Flonase p.r.n., baby aspirin, multivitamin, calcium with vitamin D twice daily, vitamin C, vitamin E, glucosamine/chondroitin, magnesium, Benadryl, CoQ10, and flaxseed oil. The patient denies abdominal pain or bloating. The patient has no current GYN complaints and denies any postmenopausal bleeding. Pap smear at that time was negative for malignancy. Palpate the thyroid gland noting size, shape, consistency as well as presence of any nodules.ĭetailed examination of the carotid arteries and jugular veins is described in the cardiovascular module.Ĭlick on the video icon to view a demonstration of examination of the neck.HISTORY OF PRESENT ILLNESS: This is a pleasant (XX)-year-old gravida 2, para 2, postmenopausal female who presents today for a routine GYN exam. A lymph node can be rolled from side to side and up and down whereas a band of muscle cannot. It is easy to mistake a band of muscle for a lymph node just as it is easy to miss abnormally enlarged lymph nodes if a careful exam is not performed. Note if only one region has enlarged lymph nodes or if all nodes are enlarged. When evaluating lymph nodes for pathology, note their size, shape, consistency, mobility, and tenderness. Next inspect the thyroid gland as the patient swallows, noting any enlargement.Įvaluate by palpation the lymphatic chains as well as the presence of any masses in the neck. Inspect the trachea, noting any deviation. Examination of the neck includes inspection for any scars, masses, glandular or nodal enlargement.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |