Complete Physical Exam

Billing codes: 03.04A CMX30 (complete physical exam) +/- 13.99BA (pelvic exam with pap smear)

ICD-9 codes: V70.0, 401.9, 272.4

Title: Complete: Pap done, Rx renewals, FIT & mammogram ordered

Summary: Comprehensive Health Exam - Pap smear performed, routine screening labs and mammogram ordered, antihypertensive and statin medications renewed.

Review of medical problems & medication renewals

• Hypertension -- Well controlled on home monitoring (averages 125/78 mmHg), asymptomatic. -- Renewed amlodipine (Norvasc®) 5 mg PO daily for 12 months.
• Dyslipidemia -- Tolerating statin well, no myalgias. -- Renewed rosuvastatin (Crestor®) 10 mg PO daily for 12 months.

Patient concerns: Mild intermittent right knee pain with stairs over the past 2 months; no swelling, locking, or giving way.

Immunizations

• Tetanus/diphtheria (Td) up to date (last 14/05/2019).
• Discussed recombinant zoster vaccine (Shingrix®); patient will consider.
• Influenza vaccine administered in clinic today.

Cancer Screening

• Colorectal: Average risk, no family history. FIT requisition provided today.
• Lung: Lifetime non-smoker, does not meet criteria for low-dose CT screening.
• Cervical: Last Pap 03/2021 (negative). Pap smear performed today.
• Breast: No family history of breast cancer. Mammogram requisition provided today (last 02/2022, BI-RADS 1).

Cardiovascular Risk Assessment and Reduction

• BMI: 26.4 kg/m2 (Height: 165 cm, Weight: 72 kg).
• Family history: Father had MI at age 68; no premature CAD.
• Lifestyle: Non-smoker, EtOH 2-3 drinks/week, no recreational drugs. Walks 30 mins 4x/week, balanced diet.
• Investigations: Fasting lipid profile ordered today.

Other screening

• Diabetes: Fasting glucose and HbA1c ordered today.
• Osteoporosis: Low 10-year fracture risk, advised vitamin D3 1,000 IU PO daily and adequate dietary calcium.
• STI: Monogamous relationship, low risk, declined screening today.

Exam

• General inspection: alert and appropriate throughout encounter, in no apparent distress, overall well appearing
• HEENT: Normocephalic, PERRLA, TMs clear bilaterally, oropharynx clear, no cervical lymphadenopathy or thyromegaly.
• Cardiac: Regular rate and rhythm, normal S1/S2, no murmurs, rubs, or gallops.
  • Blood pressure: 128/76 mmHg (HR 68 bpm)
• Respiratory: Good air entry bilaterally, clear to auscultation, no wheezes or crackles.
• Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no hepatosplenomegaly.
• Derm: no concerning lesions noted
• Neuro: grossly normal
• Pelvic: Normal external genitalia, vaginal mucosa pink, cervix normal appearance without lesions, Pap smear obtained, bimanual exam shows non-tender anteverted uterus of normal size and no adnexal masses.
• MSK: Right knee shows no effusion or erythema, full ROM, mild crepitus on flexion/extension, ligaments stable (negative Lachman and McMurray).

Assessment and management

• Renewed amlodipine (Norvasc®) 5 mg PO daily and rosuvastatin (Crestor®) 10 mg PO daily for 12 months.
• Provided requisitions for fasting lipids, HbA1c, fasting glucose, CBC, electrolytes, creatinine, FIT, and screening mammogram.
• Pap smear submitted to lab; will notify patient if abnormal.
• Administered seasonal influenza vaccine IM in left deltoid.
• Right knee mild osteoarthritis: conservative management discussed, recommended quadriceps strengthening exercises and paracetamol (acetaminophen, Tylenol®) 500 mg PO QID PRN for pain.
• Advised cholecalciferol (vitamin D3) 1,000 IU PO daily.
• Follow up in 12 months for repeat complete exam