Example_5_-_STD_Progress_Note.pdf
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- Attached to
- Electronic Health Records
- Solicitation number
- 2024-280
- Issued by
- Collin County, Texas
About this file
This document is a medical progress note for a patient named Liz Lemon, dated August 29, 2018, from a women's health clinical encounter. The progress note details a comprehensive medical examination where the patient was asymptomatic and underwent routine screening. The physical examination was thorough, covering multiple body systems including oral cavity, throat, abdominal, genitourinary, neurologic, and lymphatic areas, with no significant abnormalities detected.
The assessment indicates an STD exposure (code V01.6), and the plan included two specific diagnostic tests: a syphilis test using non-treponemal antibody and an infectious agent detection test for Chlamydia trachomatis using amplified probe technique. Both tests were ordered on the same date as the examination. The note was electronically signed by Belsy Koruthu, a Women's Health Nurse Practitioner, and appears to be part of a routine preventative health screening process.
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Text version
Progress Note
Chie f Compla in t l ASYMPTOMATIC
His tory Of Present I l lness
Rev iew o f Sys tems
¡ Denies : fatigue, fever, chills, body aches, night sweats, weight loss
¡ Denies : shortness of breath, wheezing
¡ Denies : nausea, vomiting, abdominal pain
¡ Denies : urgency, frequency, dysuria, hematuria, difficulty voiding, dyspareunia, genital sores, irregular menses, dysmenorrhea, possible pregnancy
¡ Denies : rash, itching, pigmentation changes, new skin lesions, plantar & palmar lesions, circular alopecia
¡ Denies : altered mental status, incoordination, memory difficulties, speech difficulties, loss of balance
Phys ica l Examinat ion
¡ Oral Cavity :
n Oral Mucosa : oral mucosa intact, no visable lesions n Lips : lip appearance normal, no visable lesions n Gums : gums pink, non-swollen, no bleeding present n Tongue : tongue appearance normal n Palate : hard palate normal, soft palate appearance normal
¡ Throat : no lesions, no patches, no erythema, no exudate
¡ Abdominal Examination : abdomen nontender to palpation, tone normal without rigidity or guarding, no masses present
¡ External Genitalia : no inflammation, no lesions present ¡ Vagina : normal vaginal vault, no discharge present, no inflammatory lesions present, no masses present ¡ Urethra : no inflammation present, no discharge present ¡ Cervix : appearance healthy, no lesions present, no discharges, no bleeding present, normal midline position, no
CMT, no signs of inflammation present ¡ Adnexa : nontender, no palpable masses
Patient Name: Liz Lemon
Patient ID: 1007
Sex: Female
Birthdate: January 11, 1969
Create Date: August 29, 2018
The patient .
The patient .
Pap Smear: PAP SMEAR
Constitutional
Respiratory
Gastrointestinal
Genitourinary
Integument
Neurologic
Ears, Nose, Mouth and Throat
Gastrointestinal
Genitourinary
[Date Printed:11/1/2024] Page 1 of 2[Progress Note] [Liz Lemon] [1007]
[Digital Signature Validated]
¡ Anus : no inflammation or lesions present, no discharge present, no hemorrhoids present, no anal fissures present ¡ Perineum : perineum within normal limits
¡ Neck : no lymphadenopathy present ¡ Axilla : no lymphadenopathy present ¡ Groin : no lymphadenopathy present ¡ Additional Nodes : no additional adenopathy present
¡ General Inspection : no rashes or lesions present, no areas of discoloration ¡ Body Hair : scalp palpation normal, hair normal for age, general body hair distribution normal for age
¡ Cranial Nerves : cranial nerves II - XII grossly intact ¡ Gait and Station : stable, coordination intact ¡ Cerebellar Function : cerebellar exam negative
Assessment l STD Exposure V01.6
Plan
¡ Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) - V01.6 - 08/29/2018 ¡ Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
(87491) - V01.6 - 08/29/2018
Electronically Signed by: Belsy Koruthu, WHNP-BC -Author on August 29, 2018 11:19:06 AM
Lymphatic
Skin and Subcutaneous Tissue
Neurologic
Orders
[Date Printed:11/1/2024] Page 2 of 2[Progress Note] [Liz Lemon] [1007]
[Digital Signature Validated]
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