Established patient
Vital signs: TEMPERATURE: 98.9?F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98%, WEIGHT: 161 lbs
Current allergy list: Lortab
Current Medication List:
- Lunesta Oral Tablet 3 Mg, 1 Every Day at Bedtime, As Needed
- Prozac Oral Capsule Conventional 40 Mg, 1 Every Day
- Levothyroxine Sodium Oral Tablet 100 Mcg, 1 Every Day for Thyroid Meloxicam Oral Tablet 15 Mg, 1 Every Day For Joint Pain
- Imitrex Oral Tablet 100 Mg, 1 Tab Po As Directed, Can Repeat After 2 Hours, Max 2 Per Day Phenergan 25 Mg, 1 Every 4?6 Hours, As Needed For Nausea
Chief complaint: Here for a comprehensive annual physical and pelvic examinations.
History of present illness: Pt here for routine Pap and physical. Pt reports episode of syncope 2 weeks ago. Pt went to ER and had EKG, CXR and labs and says she was sent home and per her report everything was normal. She denies episodes since that time. She does occasionally have mild mid-epigastric discomfort but no breathing problems or light-headedness. Good compliance with her thyroid meds.
Past medical history: Depression.
Family history: No cancer or heart disease, mother has hypertension.
Social history: Tobacco Use: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years.
Review of systems: Patient denies any symptoms in all systems except for HPI.
Physical Exam:
Constitutional: Well developed, well nourished individual in no acute distress.
Eyes: Conjunctivae appear normal. PERRLA
ENMT: Tympanic membranes shiny without retraction. Canals unremarkable. No abnor- mality of sinuses or nasal airways. Normal oropharynx.
Neck: There are no enlarged lymph nodes in the neck, no enlargement, tenderness, or mass in the thyroid noted.
Respiratory: Clear to auscultation and percussion. Normal respiratory effort. No fremitus.
Cardiovascular: Regular rate and rhythm. Normal femoral pulses bilaterally without bruits. Normal pedal pulses bilaterally. No edema.
Chest/Breast: Breasts normal to inspection with no deformity, no breast tenderness or masses.
GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all four quadrants.
GU: external/vaginal: Normal in appearance with good hair distribution. No vulvar irritation or discharge. Normal clitoris and labia. Mucosa clear without lesions. Pelvic support normal.
Cervix: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Specimens taken from the cervix for thin prep pap smear.
Uterus: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal.
Adnexa/Parametria: No masses or tenderness noted.
Lymphatics: No lymphadenopathy in the neck, axillae, or groin.
Musculoskeletal exam: Gait intact. No kyphosis, lordosis, or tenderness. Full range of motion. Normal rotation. No instability.
Extremities: Bilateral Lower: No misalignment or tenderness. Full range of motion. Normal stability, strength and tone.
Skin: Warm, dry, no diaphoresis, no significant lesions, irritation, rashes or ulcers.
Neurologic: CNS II-XII grossly intact.
Psychiatric: Mood and affect appropriate.
Labs/Radiology/Tests: The following labs/radiology/tests results were discussed with the patient: Alb, Bili, Ca, Cl, Cr, Glu, Alk Phos, K, Na, SGOT, BUN, Lipid profile, CBC, TSH, Pap smear.
Assessment/Plan:
Unspecified acquired hypothyroidism
What are the CPT codes reported?