CHART NOTE
Patient is here for a routine gynecologic examination. She is on Ortho-Novum birth control pills, doing well, having no difficulty with the pill. Desires refill of prescription. Her CBC and chemistry-23 are entirely normal. The patient, however, forgets to take the pill occasionally. She was advised to use alternate forms of contraception during that cycle if she misses pills.
Breast examination reveals no mass or tenderness. Abdomen is negative. Pelvic examination is entirely negative. Pap smear done. No vaginitis.
IMPRESSION
Normal gynecologic examination.
Given a refill of Ortho-Novum 1/35-21, #12. To return to office in 9 months. Advised yearly chemistry screen and HDL. To have a mammogram when turns 35 next year.
FOOTNOTE
Lines 10, 15, 22. The abbreviations were expanded.
No comments:
Post a Comment