A/P

<FIRSTNAME> is a <AGE> female who is here for routine gynecologic visit.

HPI:
She has / does not have a PCP 
She denies previous abnormal PAP smears
She reports history of abnormal PAP smear. She had RESULTS on DATE.

She has never had a mammogram
She had a mammogram last TIME ago

She has never had a Colonoscopy/Cologaurd
She had a Colonoscopy/Cologaurd last TIME ago

She had her LMP TIME

She has never had a bone density scan
She had a bone density scan last TIME ago. It was normal. Positive for osteoperosis/osteopenia
Gynecologic:
External Genitalia: 
External Genitalia exam reveals no lesions, condylomata, or rash. There is no abnormality. Labia are within normal limits with no lesions. No evidence of atrophy.
Introitus Examination: 
Introitus examination reveals introitus is normal with no abnormalities.
Vaginal Exam: 
Vaginal vault exam reveals no abnormalities, no bleeding from apex or cervical os, no signs and symptoms of infection.
Urethral Meatus: 
On examination,urethral meatus has no retraction, hypospadias, or discharge noted. No other abnormalities noted.
Urethra Exam: 
Examination of urethra shows no abnormalities.
Bladder Exam: 
Bladder examination reveals no abnormalities; no mass or tenderness noted.
Cervix Examination: 
Cervix examination is normal with respect to structural abnormality(s), infection or malignant changes.
Uterus Examination: 
Examination of uterus reveals completely normal uterus with normal size, shape, contour, position and no bleeding or any other discharge.
Digital Rectal Examination: 
Rectal Examination reveals normal sphincter tone without presence of hemorrhoids or masses.
Anus and Perineum Exam: 
Anus and perineum exam is completely normal with no tenderness, fissures, edema, dimples, hemorrhoids and any other abnormalities.
Examination for Ovulation: 
Examination for ovulation is not indicated.
Breast Inspection: 
On inspection of the breasts, both the breasts, nipples and skin over them is normal with no structural abnormality, infection or malignant changes Breast Palpation: 
Breasts are symmetric without dominant mass, nipple discharge or axillary lymphadenopathy.

General appearance: 
The patient is well-developed, well-nourished, and in no cardiorespiratory distress. <HE/SHE> is alert and oriented to time, place, and person. The patient ambulates to the examination room without assistance. <HE/SHE> is able to sit comfortably on the examination table without difficulty or evidence of pain.

Head: 
Normocephalic and atraumatic. No deformities, lesions or mass.

Skin: 
Gross inspection of skin demonstrates no evidence of abnormality. Hair and nails are also normal. Skin is warm and dry.

Gastrointestinal: 
Soft and nontender. Audible bowel sounds. No organomegaly. No visible scars, hernias or sinuses are seen.

Respiratory: 
Good air movement bilaterally. Lungs are clear to auscultation. No wheezes, rales, rubs or rhonchi are noted.

Cardiovascular: 
PMI is nondisplaced and normal in character, no heave or abnormal pulsation. Normal sinus rhythm. Distinct S1 and S2. No audible click, murmur, gallop or rub.


A&P:
A/P done. PAP done and sent to lab. 
Patient to RTO in 1 year for A/P
Cultures done for STI screen.
Advised and ordered mammogram. 
Advised and ordered bone density scan
Advised colonoscopy. Referred to gastroenterologist
Advised and ordered cologaurd 
PHQ-9 done. No f/u needed / Refer to APEX / Patient is undergoing treatment