Female AWV Note - Cannon

Chief Complaint: * Annual Wellness Visit HPI: 1. The patient is a [45]-year-old female presenting for her annual wellness visit. She reports no new complaints. Female AWV (if any of the following points were not discussed, write "n/a" next to them) - Nutrition: Patient reports a balanced diet with plenty of fruits, vegetables, and lean protein. - Exercise: Patient exercises regularly, including 30 minutes of cardio 3 times per week and strength training twice per week. - Falls: n/a - EtOH/Tobacco: Patient denies use of alcohol or tobacco. - HTN screen: BP today is 120/78. - Cholesterol: LDL 110. - 10 year CV risk %: 5% - Pap Smear: Pap smear discussed, scheduled for next month. - Taking Folate?: Patient is taking folate. - Teratogenic Meds: n/a - Contraceptive method: Patient uses oral contraceptives. - STD screen: n/a - One time HIV/HBV/HCV screen: Patient has been screened for HIV, HBV, and HCV, all negative. - Skin cancer screening: n/a - Depression (PHQ2/9): PHQ-2 score is 0. - Anxiety (GAD2/7): GAD-2 score is 1. - Med review: Medication list reviewed and confirmed. - Mammogram: Mammogram discussed, scheduled for next month. - DEXA: DEXA discussed, scheduled for next year. - Colon CA screen: Colonoscopy discussed, scheduled for next year. - Lung CA Screen: n/a - Advance Care Planning: Advance care planning discussed, patient has an advance directive. Medical Diagnoses: 1. Hypertension 2. Hyperlipidemia Specialist Care: 1. Cardiologist: Dr. Smith Medications: 1. Lisinopril 20mg PO daily 2. Atorvastatin 40mg PO daily Review of Systems (This section should not include interpretations by the patient or physician. It should only include subjective signs and symptoms mentioned by the patient.) Constitutional: No fever, chills, fatigue, or weight changes. Eyes: No vision changes, redness, pain, or discharge. Ears, Nose, Throat: No hearing loss, tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia. Cardiovascular: No chest pain, palpitations, or edema. Respiratory: No shortness of breath, cough, or wheezing. Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or abdominal pain. Genitourinary: No dysuria, hematuria, urinary frequency, or urgency. Musculoskeletal: No joint pain, stiffness, or swelling. Skin: No rashes, lesions, or itching. Neurologic: No headaches, dizziness, numbness, or weakness. Psychiatric: No anxiety, depression, or mood changes. Endocrine: No polyuria, polydipsia, or heat/cold intolerance. Hematologic/Lymphatic: No easy bruising, bleeding, or lymphadenopathy. Allergic/Immunologic: No allergies, sneezing, or hives. Physical Exam (Include both normal and abnormal findings explicitly mentioned in the transcript. Use proper, medical terminology. Only include headings for organ systems that are explicitly examined in the transcript. Leave out systems that are not mentioned. Do not include interpretations mentioned by the patient or physician, only objective signs and symptoms.) Vital Signs: BP 120/78, HR 72, RR 16, Temp 98.6 Head: Normocephalic, atraumatic. Eyes: PERRLA. Ears, Nose, Throat: Mucous membranes moist, no erythema or exudates. Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Gastrointestinal: Soft, non-tender, no masses or organomegaly. Musculoskeletal: Full range of motion in all extremities. Skin: No rashes or lesions. Neurologic: Alert and oriented x 3. Labs / Imaging / Diagnostic Tests: 1. Lipid panel: LDL 110 (last month) Assessment & Plan (This entire section should use detailed, proper medical terminology. The first problem listed should always be Preventive Care.) 1. Preventive Care [Z00.00] Assessment: The patient is a [45]-year-old female presenting for her annual wellness visit. She is up-to-date on all preventative screenings and immunizations. She reports a healthy lifestyle with a balanced diet and regular exercise. She denies tobacco and alcohol use. She has a family history of cardiovascular disease. Plan: * Discussed importance of continued healthy lifestyle. * Scheduled Pap smear and mammogram for next month. * Scheduled DEXA and colonoscopy for next year. * Reviewed and updated advance directive. * Provided patient with educational materials on healthy lifestyle. 2. Hypertension [I10] Assessment: The patient's blood pressure is well-controlled on current medication. Plan: * Continue Lisinopril 20mg PO daily. * Monitor blood pressure at home. * Follow up in 3 months. 3. Hyperlipidemia [E78.5] Assessment: The patient's LDL is slightly elevated. Plan: * Continue Atorvastatin 40mg PO daily. * Repeat lipid panel in 3 months. * Discussed importance of diet and exercise. Patient Name: [Patient Name] Date of Procedure: 1 November 2024 Procedure Performed: Pap Smear Indication: Routine screening Pre-Procedure Diagnosis: Routine screening Post-Procedure Diagnosis: Routine screening Details of Procedure: Consent: Informed consent was obtained, including discussion of risks, benefits, and alternatives. Preparation: Patient placed in dorsal lithotomy position. Speculum inserted. Cervix visualized. Procedure Steps: Cervical cells collected using a cytobrush and spatula. Sample placed in ThinPrep vial. Findings: Normal cervix. Complications: None. Post-Procedure Care: Patient tolerated the procedure well. Post-procedure monitoring: Patient advised to contact the office if she experiences any bleeding or pain. Follow-up plan: Results will be available in 2 weeks. Patient will be contacted with results. Medications Administered: None