GYN Extended

[text size="2"]yo G[text size="2"] P[text size="2"] with LMP of [text size="10"] here for well-woman exam.
-Last Pap- [text size="3"] years ago. Results: [select value="normal|other- "][text size="40"]
-Hx of abnormal Pap test: [select value="no|YES"][text size="40"]
-Age of menopause: [select name="menopause" value="not yet reached|started withing past 1/2yrs|"][conditional field="menopause" condition="(menopause).isNot('not yet reached')"] [text size="4"]
[/conditional][conditional field="menopause" condition="(menopause).is('not yet reached')"]
-Frequency of menstrual cycles- every [text size="8"] days?
-Menstrual cycle regularity- [select value="regular|irregular"]
-Duration of menses- [text size="8"] days
-Amount of bleeding on heaviest days- [text size="4"] pads/tampons per day
-Between cycle bleeding- [select value="no|YES"]
[/conditional]-Unusual vaginal discharge- [select value="no|YES"]
-Sexually active- [select name="Sex" value="no|Yes"][conditional field="Sex" condition="(Sex).is('Yes')"]
-Number of sexual partners in past year *[text size="3"]*[/conditional]
-Current method(s) of birth control? [checkbox value="Condoms|Withdrawal method|Calendar method (timing intercourse around ovulation)|Birth control pills|Birth control patch (OrthoEvra)|Vaginal ring (NuvaRing)|Injection (DepoProvera)|Nexplanon/ Mirena|Tubal Ligation/ Hysterectomy|Post-menopausal|None"]
-History of STD?- [select value="no|YES"]
-Problematic hot flashes- [select value="no|YES"]
-Currently on hormone replacement- [select value="no|YES"]
-Smoking- [select value="no|YES"]
-Hx of breast problems- [select value="no|YES"] 
-Last mammogram- [select value="n/a|date-"] [text size="20"]
-Reports being abused- [select value="no|YES"]
-Feels safe at home? [select value="yes|NO"]

Other concerns: [textarea]
EXAM
[textarea name="variable_2" cols=80 rows=2 default="General appearance: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea name="variable_8" cols=80 rows=1 default="Neck: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
[textarea name="variable_9" cols=80 rows=3 default="Cardiac: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
[textarea name="variable_10" cols=80 rows=2 default="Lungs: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea name="variable_21" cols=80 rows=1 default="BREASTS: No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy."]
[textarea name="variable_22" cols=80 rows=3 default="PELVIC: Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness."]

Plan
1.
2.
3.
yo G P with LMP of here for well-woman exam.
-Last Pap- years ago. Results:
-Hx of abnormal Pap test:
-Age of menopause: -Unusual vaginal discharge-
-Sexually active-
-Current method(s) of birth control?
-History of STD?-
-Problematic hot flashes-
-Currently on hormone replacement-
-Smoking-
-Hx of breast problems-
-Last mammogram-
-Reports being abused-
-Feels safe at home?

Other concerns:
EXAM







Plan
1.
2.
3.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.44, 39 form elements, 63 boilerplate words, 13 text boxes, 7 text areas, 1 checkboxes, 15 drop downs, 3 conditionals, 46 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: