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Annual Health Maintenance Transcription Sample Report

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who comes in today for a routine physical. Her last physical was last year. She just had a Pap recently. She states that she has a couple of different problems that she would like to address. One is that she has had a lot of gas pain, and it is very uncomfortable. She is bloated often times. She has not been eating regularly, but she has noticed that her belly swells a lot. Lately, she has been a little dizzy and lightheaded. She will get very lightheaded and she will start to have a little shakes. Has fainted a couple of times. Another problem is heartburn. She said that she has had some heartburn. The patient has a little shortness of breath and some shooting pain; it lasts for a minute or so, and it is especially on the left side.

MEDICATIONS:  Tri-Sprintec.

ALLERGIES:  No known allergies.

PAST MEDICAL HISTORY:  Unremarkable. The patient does have mitral valve prolapse.

FAMILY HISTORY:  A paternal aunt was recently diagnosed with breast cancer at age 50. Her father is healthy. Her mother is healthy.

SOCIAL HISTORY:  The patient does not smoke, does not drink alcohol.

HEALTH MAINTENANCE:  The patient does exercise all the time. She is very active. She does wear her seat belt. She does use sunscreen. Her last Pap was on MM/DD/YYYY. Her last period was MM/DD/YYYY. She has never had a STD. Never had any abuse or any domestic violence.

REVIEW OF SYSTEMS:  Denies any palpitation. Does have occasional shortness of breath with the shooting pain running across her chest, no real chest pain per se. No migraine headaches. Sometimes constipated, but no diarrhea, mostly no blood in her stools. No musculoskeletal pain, no headaches. Review of systems basically noncontributory, except for, most likely, irritable bowel syndrome and heartburn.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a pleasant female, in no acute distress. Well developed, well nourished.
VITAL SIGNS:  The patient is 5 feet 7 inches tall. She weighs 140 pounds. Her blood pressure is 118/68.
HEENT:  Head is normocephalic and atraumatic. Pupils are equal and reactive to light with good red light reflex. TMs are pearly gray, clear, with good cone of light reflex. Nasal mucosa is pink. Oropharynx is pink. No exudate.
NECK:  Supple. No lymphadenopathy noted. No carotid bruits. No thyroid mass or thyromegaly.
LUNGS:  Clear bilaterally. No wheezes, rales or rhonchi.
HEART:  Rate has regular rate and rhythm. Normal S1 and S2.
EXTREMITIES:  Lower extremities without cyanosis, clubbing or edema.
GYNECOLOGIC:  Done just recently.

ASSESSMENT AND PLAN:
1.  The patient will go downstairs for followup blood work. We did postural blood pressures, and they were perfectly fine. She does not have postural hypertension. Also, do 24-hour urine for catecholamines to rule out any adrenal problems or thrombocytosis.
2.  For the patient’s heartburn and gas pains, we did tell her to try to take, maybe, omeprazole, which will help with the heartburn. She does have to eat healthy. She will try to eat six small meals a day. She does have to eat, and we do not think she has enough of food in her system post all the exercise that she does do.
3.  The patient has dizziness and a question of fainting. Most likely, it could be a questions of hypoglycemia. We will do a glucose tolerance test to rule out that and also we will do blood work.
4.  For the patient’s shortness of breath and shooting pain because of her mitral valve prolapse, we will get a stress and do an echo and a Myoview to rule out any abnormalities.
5.  We will follow up with the results by a letter or by phone call.