Complete Note, Gynecology
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[text size="2"] YOF, G[text size="2"] P[text size="2"], here for [checkbox name="variable_1" value="well-woman exam|Problem Visit"]
Patient Reports [select name="variable_1" value="no changes to her PMH|AUB|dysmenorrhea|amenorrhea|menorrhagia|other"]
[textarea]

PMH
-LMP [select name="variable_2" value="less than 30 Days ago|more than 30 days ago|None D/t IUD|None D/t Post Menopausal|None D/t Lactational Amenorrhea"]
-Birth Control Method: [text size="10"]
-Last Pap [text size="3"] years ago. Results: [select value="Cytology negative|ASCUS|LSIL|HSIL"] & [select value="-|+"] HPV; with [select value="-|+"]Hx of abnormal Pap [text size="40"]
-Last Mammogram [text size="3"] years ago. Results: [select value="BI-RADS 0|BI-RADS 1|BI-RADS 2|BI-RADS 3|BI-RADS 4|BI-RADS 5|BI-RADS 6"]; with [select value="-|+"]Hx of abnormal Mamogram[text size="40"]

[textarea cols=80 rows=1 default="Previous Surgeries: None
Current Medications: None"]


ROS
[textarea cols=80 rows=1 default="CONSTITUTIONAL: denies fever, chills, fatigue"]
[textarea cols=80 rows=1 default="NECK: denies painful or swollen nodes."]
[textarea cols=80 rows=1 default="ENDOCRINE: denies tremor/palpitations/heat or cold intolerance/unusual fatigue; denies polyuria/polydipsia/polyphagia"]
[textarea cols=80 rows=1 default="RESPIRATORY: denies cough/sputum/SOB/chest pain."]
[textarea cols=80 rows=1 default="CARDIOVASCULAR: denies CP/SOB/palpitations/edema."]
[textarea cols=80 rows=1 default="GASTROINTESTINAL: denies constipation/nausea/vomiting/diarrhea/blood in stool."]
[textarea cols=80 rows=1 default="BREASTS: denies pain/tenderness/lumps/masses/nipple discharge."]
[textarea cols=80 rows=1 default="GENITOURINARY: denies dysuria/frequency/vaginal bleeding/vaginal pain/blood in urine/incontinence/abnormal vaginal discharge/vaginal dryness/dyspareunia"]
[textarea cols=80 rows=1 default="PSYCHIATRIC: denies depression/anxiety."]

OBJECTIVE

Vitals:
[text name="variable_1" default="WNL"]

EXAM
[textarea name="variable_2" cols=80 rows=2 default="GENERAL: 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."]

A/P
[textarea name="variable_1" default="1. Encounter for gynecological examination (general) (routine) without abnormal findings"]


PROCEDURES/LABS:
[text name="variable_1" default="None"]


Return to office in [checkbox name="variable_2" value="1 week|2 weeks|1 month|6 weeks|3 months|6 months|1 year|Within 5 days of the first day of the next period"]
[textarea cols=80 rows=1 default=""]
YOF, G P, here for
Patient Reports


PMH
-LMP
-Birth Control Method:
-Last Pap years ago. Results: & HPV; with Hx of abnormal Pap
-Last Mammogram years ago. Results: ; with Hx of abnormal Mamogram




ROS










OBJECTIVE

Vitals:


EXAM







A/P



PROCEDURES/LABS:



Return to office in

Result - Copy and paste this output:

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