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Annual Health Assessment Transcription Sample Report

REASON FOR VISIT:  The patient is here for an annual health assessment.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman who is here to have an annual health assessment and meet me as a new primary care physician. The patient was recently evaluated and treated for diverticulitis. She had a subsequent colonoscopy about a week ago that confirmed diverticulosis, but no other colon lesions. She has been doing well since her discharge from the hospital over the summer. She has no particular symptoms referable to that today. The patient is followed by Behavioral Health for depression and anxiety and is doing well on Wellbutrin as well as Ativan at bedtime. She was diagnosed with osteoporosis. She suffered a metacarpal and a metatarsal fracture in the last year. Vitamin D and PTH levels were normal. She does weightbearing exercise several times a week. She is taking actually high doses of vitamin D, up to 2000 international units a day, and is taking sufficient calcium about 1400 or 1500 mg a day. She is also on Fosamax and tolerating that. She has arthritis of her hands and is taking fish oil and seems to be doing well on that.

PAST MEDICAL HISTORY:  Diverticulitis, diverticulosis, depression and anxiety, osteoarthritis, osteoporosis, basal cell skin carcinoma and actinic keratoses for which she sees a dermatologist yearly. She has had a trigger release, bunion surgery, fractures of her metacarpal and metatarsal bones. She has had a breast augmentation. She is status post C-section x3.

ALLERGIES:  No known drug allergies.

MEDICATIONS:  Fish oil, selenium, Wellbutrin 200 mg daily, calcium with vitamin D 1400 mg/2000 international units, I have asked that she decrease her vitamin D level to about 1000 units a day. Fosamax 70 mg weekly, acyclovir 400 mg daily for HSV prophylaxis, Colace, and lorazepam 1 mg at bedtime.

FAMILY HISTORY:  Notable for diabetes, heart disease, hyperlipidemia, hypertension, skin cancer, breast cancer and asthma. No family history of colon, ovarian, or prostate cancer.

HEALTHCARE MAINTENANCE:  The patient is a nonsmoker. One drink a week. No illicit drug use. She does weightbearing exercise 3-4 times a week and walks twice a week. She gets calcium and vitamin D in her diet and a supplement. She is good about seat belts, regular dental care and flossing. She uses sunscreen always. No history of tattoos. No blood transfusions. She is in a monogamous relationship with a man. No history of sexually transmitted diseases other than HSV. HIV negative in the past with no interval risk. Paps have all been normal, and she is requesting referral to a gynecologist.

CANCER SCREENING:  Last Pap was one year ago, and she is going to repeat with a new gynecologist. Last mammogram was normal. Last breast exam was fine. Colonoscopy last month was negative. Bone density, 6 months ago, showed osteoporosis.

IMMUNIZATIONS:  Tetanus booster last year. She had a history of varicella vaccine. She gets a flu vaccine regularly.

PHYSICAL EXAMINATION:  Blood pressure 86/72, 122 pounds. Afebrile, well-appearing woman. Oropharynx:  Clear. Anicteric sclerae. Neck:  No lymphadenopathy. Normal thyroid. Axilla:  No lymphadenopathy. Lungs:  Clear. Heart:  Regular rate and rhythm. No murmurs. Breasts:  Exam deferred to gynecologist at the patient’s request. Abdomen:  Soft, nontender, no organomegaly. Extremities:  Show no edema. Skin:  Shows marked sun damage. Neurologically nonfocal.

IMPRESSION AND PLAN:  The patient is a (XX)-year-old woman who is generally doing well, although she has history of multiple issues.
1.  Health maintenance:  Her vaccines are up to date. I recommended a flu shot. Cancer screening is up to date, and she has plans to see the gynecologist for annual Pap smear. Her lipids last year were fine with an LDL 146, HDL of 70, triglycerides of 54. I recommended repeat this fasting, sometime in the next 6-12 months. We talked about appropriate amounts of calcium, vitamin D and weightbearing exercise for her osteoporosis. She is going to continue the Fosamax, which she is tolerating. Repeat bone density due in 18 months.
2.  Diverticulosis:  We reviewed the colonoscopy report from her recent scope. We talked about high-fiber diet. We have e-mailed her the up-to-date handout on diverticulosis. We discussed that if she gets recurrent lower abdominal symptoms, especially fever or persistent pain, then she should be evaluated as she is at risk for recurrent bouts of diverticulitis.
3.  Depression and anxiety, seem well controlled on her current regimen.
4.  Skin cancer history:  Reinforced sunscreen, and she sees a dermatologist regularly.

The patient is going to return to see me for an annual health assessment.