Well Woman Exam VMC Clinic

HISTORY:
[checkbox name="historian" value="provided by patient||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t language skills|"][textarea cols=70 rows=1]
Purpose of Visit/CC:
[checkbox name="purpose" value="annual screening|new problem|follow up on abnormal|"][textarea cols=70 rows=1]
Breast Sx:
[checkbox name="breast_cc" value="does not report||pain|swelling|lump|discharge|skin changes|abnormal imaging|family history|"][textarea cols=70 rows=1]
GI Sx:
[checkbox name="abdominal_cc" value="does not report||upper abd pain|lower abd pain|diarrhea|constipation|nausea/vomiting|"][textarea cols=70 rows=1]
Menstrual Sx:
[checkbox name="menstrual_cc" value="does not report||irregular menstruation|heavy menses|painful menses|spotting|missed|"][textarea cols=70 rows=1]
LMP: [textarea cols=10 rows=1 default="N/A"]
Urinary Sx:
[checkbox name="urinary_cc" value="does not report||burning|frequency|pain with urination|blood in urine|back pain||stress incontinence|urge incontinence|"][textarea cols=70 rows=1]
Vaginal Sx:
[checkbox name="vaginal_cc" value="does not report||clear discharge|thick discharge|yellow discharge|brown discharge||itching|skin lesions||painful intercourse|postcoital bleeding|prolapse||vaginal bleeding|vaginal clots|vaginal tissue||started several days ago|started today|"][textarea cols=70 rows=1]
Sexual Hx:
[checkbox name="sexual" value="declined|N/A||active|inactive|no new partners||known/suspected exposure|inconsistent condom use|new partner|partner w STI|non-monogamous partner||vaginal|oral|anal||previous STI|"][textarea cols=70 rows=1]
Last unprotected intercourse: [textarea cols=10 rows=1 default="N/A"]
Birth Control/HRT:
[checkbox name="birth_control" value="none||BCP|Depo|implant|IUD|BTL|condoms|"][textarea cols=70 rows=1]
Smoking:
[checkbox name="smoking" value="no|yes|"][textarea cols=70 rows=1]

HPI:
Recent History: [textarea cols=40 rows=1]
[checklist name="recent" value="stress|travel|new sexual partner|injury|PCP/UC visit|ER visit|hospitalization/surgery/procedure|new medications|antibiotic use|diagnostic study"]
Duration:
[checkbox name="duration" value="N/A|hours|days|weeks|"][textarea cols=70 rows=1]
Medication List Reviewed: [checkbox name="medreview" value="no change|new medications|discontinued medications|side effects|"][textarea cols=70 rows=1]
Symptoms:
[checkbox name="sx" value="N/A||increasing in severity|remaining constant|decreasing in severity||constant|come and go|cyclic|worse with menses|worse with caffeine|"][textarea cols=70 rows=1]
Imaging:
[checkbox name="imaging" value="N/A||mammogram UTD|normal|abnormal|mammogram not UTD||ultrasound|MRI|"][textarea cols=70 rows=1]
PAP:
[checkbox name="imaging" value="N/A||normal|abnormal|unsatisfactory||EC/TZ component present| EC/TZ component absent||ASC-US|LSIL|ASC-H|HSIL|AGC|AIS|CIS||HPV POS|HPV NEG|"][textarea cols=70 rows=1]
Family Hx:
[checkbox name="family" value="N/A||breast ca|ovarian ca|colon ca|"][textarea cols=70 rows=1]
PMH:
reviewed
[checkbox name="pmh" value="noncontributory||frequent UTIs|kidney stones|incontinence||ovarian cyst|endometriosis|fibroids||breast ca||DM|immunosuppression|"][textarea cols=70 rows=1]
Pregnancy: [textarea cols=10 rows=1 default="N/A"]
[checkbox memo="pregnancy" name="notes2" value=" "][conditional field="notes2" condition="(notes2).is(' ')"][checklist name="gyn_symptoms" value="ectopic pregnancy|induced abortion|spontaneous abortion"][/conditional][textarea cols=70 rows=1]
PSH:
[checkbox name="psh" value="breast biopsy|breast implants|breast reduction||CS|salpingo-oophorectomy|hysterectomy||colposcopy|D&C|"][textarea cols=70 rows=1]


REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL: [textarea cols=40 rows=1]
[checklist name="constitutional_symptoms" value="fever|night sweats|hot flashes|unintentional wt loss"]
HEAD/FACE: [textarea cols=40 rows=1]
[checklist name="head_symptoms" value="headache|scalp swelling|trauma|facial numbness"]
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="decrease in vision|halos|dryness|redness|discharge"]
EARS: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|pressure|discharge|wax|hearing loss|ringing"]
NOSE: [textarea cols=40 rows=1]
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache|jaw pain/clicking|changes in taste"]
THROAT: [textarea cols=40 rows=1]
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness|globus"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|lightheadedness|fainting|exertional dyspnea|orthopnea|rapid wt gain|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump"]
MSK: [textarea cols=40 rows=1]
[checklist name="msk_symptoms" value="myalgias|neck pain|back pain|shoulder pain|hip pain|knee pain|chronic pain/meds|joint pain/deformity|localized muscle/soft tissue pain/swelling"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|speech difficulty|tremor|seizures|urinary/bowel changes|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|withdrawal|depression|apathy|anxiety|mood swings|memory loss|insomnia"]
ENDO: [textarea cols=40 rows=1]
[checklist name="endo_symptoms" value="cold intolerance|skin dryness|hair loss"]
LYMPH/HEMA: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"]
ALLERGIES/IMMUNE: [textarea cols=40 rows=1]
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds"]

Physical examination
General: [textarea name="variable_77" default="AAOx3, NAD"]
HEENT: [textarea name="variable_78" default="NC/AT, PERRLA, EOMI, mmm, no LAD"]
Cardiovascular: [textarea name="variable_79" default="RRR, +s1, +s2, no M/R/G"]
Pulmonary: [textarea name="variable_80" default="CTA b/l, no W/R/R"]
Abdominal: [textarea name="variable_81" default="soft, NT/ND, no hepatosplenomegaly, +bowel sounds"]
Neurological/MSK/Extremities: [textarea name="variable_82" default="CN 2-12 intact, normal motor strength, normal sensation, normal reflexes "]

Clinical Breast Exam:
Right Breast: [textarea cols=40 rows=1]
[checklist name="right_breast" value="implant|density|skin changes|tenderness|nipple changes|nipple discharge|mass|axillary LAD|supraclavicular LAD|infraclavicular LAD"]

Left Breast: [textarea cols=40 rows=1]
[checklist name="right_breast" value="implant|density|skin changes|tenderness|nipple changes|nipple discharge|mass|axillary LAD|supraclavicular LAD|infraclavicular LAD"]

Mass:
[checkbox name="mass" value="none||r breast|left breast||round|oval|irregular||well-defined margins|ill-defined margins||less than 1 cm|1 to 3 cm|larger than 3 cm|| soft|firm|rubbery|hard||fixed|mobile|"][textarea cols=70 rows=1]

Pelvic Exam:
[checkbox name="pelvic" value="normal||below|declined|"][textarea cols=70 rows=1]
Vulva:
[checkbox name="vulva" value="normal||atrophy|discharge|condylomata|"][textarea cols=70 rows=1]
Vagina:
[checkbox name="vagina" value="normal||cystocele|rectocele|Bartholin's||erythema|atrophy||milky discharge|curdy discharge|greenish/yellowish discharge||active bleeding|clots|tissue in vault|"][textarea cols=70 rows=1]
Cervix:
[checkbox name="cervix" value="normal|non-tender||motion tenderness|erosions|Nabothian cyst|discharge|"][textarea cols=70 rows=1]
Uterus:
[checkbox name="uterus" value="normal||tenderness|mass|enlarged|"][textarea cols=70 rows=1]
Adnexa:
[checkbox name="adnexa" value="non-tender||tenderness|enlargement|masses|"][textarea cols=70 rows=1]
Rectal:
[checkbox name="rectal" value="declined||normal tone||hemorrhoids|masses|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|previous visits|PMP|laboratory/diagnostic studies|"][textarea cols=70 rows=1]

OUTSIDE LABS:
[checkbox name="collected" value="PAP|urine|BV swab||CBC|CMP|TSH|HgbAIC|Lipids|STI|"][textarea cols=70 rows=1]

Significant laboratory values:
[textarea name="variable_85" default=""]

Radiology:
[textarea name="variable_36" default=""]

Microbiology:
[textarea name="variable_37" default=""]
UA:
[checkbox name="office_ua" value="non-specific changes|normal|suggestive of UTI||leukocytes|nitrites|glucose|blood|declined||urine cx sent out|"][textarea cols=70 rows=1]

hcg:
[checkbox name="office_hcg" value="N/A||positive home test||negative clinic test|positive clinic test|declined|"][textarea cols=70 rows=1]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs,exam & testing findings|reporting medication side effects to clinic immediately|appropriate follow up with PCP|weight reduction|dietary changes|exercise|family planning|contraceptive options|emergency contraception|safe sex|SBE|mammogram if older than forty|osteoporosis prevention & screening|smoking cessation|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified during visit||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|failed to obtain old records|failed to complete referrals or testing|failed to bring medications for med review|poor compliance with medication regimen||incomplete history|vague shifting complaints|history not supported by objective findings||multiple comorbidities|recent hospitalization||polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|medication use in response to environmental stress|intolerance of multiple meds|overreliance on short-acting meds||multiple office contacts|frequent ER/UC visits||altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="none|ABX|Pyridium 100 mg TID #6|Rx for suspected vaginosis|Rx for suspected STI||electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN||RTC 1 week|RTC 6 months|RTC 12 months||screening mammo|diagnostic mammo|diagnostic ultrasound||surgeon|GYN||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport|declined emergency transfer|left clinic before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]

Health maintenance
Cancer screening:
- Colonoscopy: [text name="variable_43" default=""]

Vaccinations:
- Flu vaccine: [text name="variable_44" default=""]
- Pneumococcal (PPSV23/13): [text name="variable_45" default=""]
- Td/Tdap: [text name="variable_46" default=""]

For females:
- Mammogram: [text name="variable_47" default=""]
- FRAX/QFracture Score: (If FRAX Score > 10%, get DEXA scan for osteoporosis); https://qfracture.org/ [text name="variable_48" default=""]
- Refer to Gyn for PAP smear if 21 or above: [text name="variable_49" default=""]

Other:
- ASCVD Score: (if >7.5, start high intensity statin; if >10, add ASA) [text name="variable_50" default=""]
- PPD/Quantiferon (if high risk for TB, i.e, jail, homeless/lives in shelter, recent TB exposure): [text name="variable_51" default=""]

For diabetics:
- Refer to Ophthalmology for Glaucoma Screening/Diabetic Retinopathy if with h/o DM: [text name="variable_52" default=""]
- Refer to Podiatry for Podiatry Diabetic Foot Screening if with h/o DM: [text name="variable_53" default=""]

For smokers:
- If 55-80 y/o who have a 30 pack-year smoking history & currently smoke or have quit w/in the past 15 years, LDCT: [text name="variable_54" default=""]
- >65 with h/o Smoking, send for US Abdomen for AAA screening: [text name="variable_55" default=""]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified during visit||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|failed to obtain old records|failed to complete referrals or testing|failed to bring medications for med review|poor compliance with medication regimen||incomplete history|vague shifting complaints|history not supported by objective findings||multiple comorbidities|recent hospitalization||polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|medication use in response to environmental stress|intolerance of multiple meds|overreliance on short-acting meds||multiple office contacts|frequent ER/UC visits||altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]


A/P:

PLAN OF CARE:
[comment memo="DDX:

[checkbox name="discussed" value="POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]P

[checkbox name="disposition" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN||RTC 1 week|RTC 6 months|RTC 12 months||screening mammo|diagnostic mammo|diagnostic ultrasound||surgeon|GYN||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport|declined emergency transfer|left clinic before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]


INSTRUCTED ON:
[checkbox name="instructions" value="vital signs,exam & testing findings|reporting medication side effects to clinic immediately|appropriate follow up with PCP|weight reduction|dietary changes|exercise|family planning|contraceptive options|emergency contraception|safe sex|SBE|mammogram if older than forty|osteoporosis prevention & screening|smoking cessation|"][textarea cols=70 rows=1]

Counseling given on:
- Smoking and alcohol cessation and abstaining from substance abuse
- Driving with a seatbelt
- Safe sex practices
- Regular exercise, i.e., low impact, stationary bike, swimming
- Medication compliance
- Weight reduction
- Dietary counseling: low-fat diet, decrease whole dairy products (whole milk, cheese, and butter), fatty meats, and fried foods. Eat more fruits, vegetables, whole-wheat breads, lean chicken, and fish (such as salmon or tuna). Attempt at counting calories, use a calorie tracker such as MyFitnessPal, strive for 2700 kcal per day, small frequent meals, and avoid concentrated sweets.


OUTSIDE LABS Ordered:
[checkbox name="collected" value="|CBC|CMP|HGBAIC|Lipids|TSH|PAP|urine|BV swab|STI|"][textarea cols=70 rows=1]