Female Annual Wellness Visit Note

Chief Complaint

• Female Annual Wellness Visit
• Right knee pain
• Actinic keratosis cryo

HPI

1. Right knee pain: 52 yo female c/o insidious onset R medial knee pain x 3 mos. Described as dull ache, 4/10 severity, worse w/ prolonged standing and stairs, relieved by rest and paracetamol (acetaminophen, Tylenol®) 500 mg PO PRN. No prior hx of knee trauma or surgery.
2. Essential hypertension: Well-controlled on current regimen. Home BPs averaging 125/78 mmHg. Asymptomatic; denies headache, vision changes, or chest pain.

Female AWV

• Nutrition: Mediterranean diet; limits processed foods and red meat.
• Exercise: Brisk walking 30 mins 4x/wk; limited recently by R knee pain.
• Falls: Denies falls in past yr.
• EtOH/Tobacco: Never smoker. EtOH: 1-2 glasses of wine/wk.
• HTN screen: 128/82 mmHg
• Cholesterol: LDL 112 mg/dL (10/04/2025)
• 10 year CV risk %: 2.1%
• Pap Smear: Up to date (negative co-testing 2023); next due 2028.
• Taking Folate?: No (postmenopausal).
• Teratogenic Meds: Lisinopril (not applicable, postmenopausal).
• Contraceptive method: None (postmenopausal).
• STD screen: Declined today; monogamous partner.
• One time HIV/HBV/HCV screen: HIV non-reactive, HCV Ab non-reactive, HBV surface Ag negative (12/05/2021).
• Skin cancer screening: 4 mm erythematous, scaly papule on R dorsal forearm.
• Depression (PHQ2/9): PHQ-2 score: 0. Denies depressed mood or anhedonia.
• Anxiety (GAD2/7): GAD-2 score: 1. Denies persistent worry.
• Med review: medication list reviewed and confirmed
• Mammogram: Ordered bilateral screening mammogram today.
• DEXA: Discussed; deferred until age 65 given lack of risk factors.
• Colon CA screen: Cologuard negative (2024); next due 2027.
• Lung CA Screen: Not indicated (never smoker).
• Advance Care Planning: Has Healthcare POA (husband); copy on file.

Medical Diagnoses

1. Essential hypertension
2. Hyperlipidemia
3. Postmenopausal state

Specialist Care

1. Dr. Sarah Jenkins, Dermatology

Medications

1. lisinopril (Prinivil®) 10 mg PO daily
2. atorvastatin (Lipitor®) 20 mg PO daily
3. paracetamol (acetaminophen, Tylenol®) 500 mg PO PRN pain

Supplements

1. colecalciferol (Vitamin D3) 1,000 IU PO daily
2. calcium citrate 500 mg PO daily

Review of Systems

Constitutional: Denies fever, chills, fatigue, or weight loss.

Eyes: Denies vision changes, diplopia, or eye pain.

Ears, Nose, Throat: Denies hearing loss, tinnitus, sinus congestion, or sore throat.

Cardiovascular: Denies chest pain, palpitations, orthopnea, or lower extremity edema.

Respiratory: Denies SOB, cough, or wheezing.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, or hematochezia.

Genitourinary: Denies dysuria, frequency, urgency, or postmenopausal bleeding.

Musculoskeletal: Positive for R knee pain and stiffness. Denies joint swelling, erythema, or back pain.

Skin: Positive for rough, scaly spot on R forearm. Denies new or changing nevi or pruritus.

Neurologic: Denies headaches, dizziness, syncope, numbness, or tingling.

Psychiatric: Denies depression, anxiety, or insomnia.

Endocrine: Denies heat/cold intolerance, polydipsia, or polyuria.

Hematologic/Lymphatic: Denies easy bruising, bleeding, or lymphadenopathy.

Allergic/Immunologic: Denies seasonal allergies or frequent infections.

Physical Exam

Constitutional: Well-developed, well-nourished female in NAD.

Vital Signs: BP 128/82 mmHg, HR 72 bpm, RR 14/min, Temp 36.8 °C, SpO2 99% RA, Wt 68 kg, Ht 165 cm, BMI 25.0 kg/m2.

Head: Normocephalic, atraumatic.

Eyes: PERRLA, EOMI. Conjunctivae clear, no scleral icterus.

Ears, Nose, Throat: TMs pearly gray bilaterally. Oropharynx clear, mucous membranes moist.

Neck: Supple, no JVD, no thyromegaly or lymphadenopathy.

Cardiovascular: RRR, normal S1/S2, no murmurs, rubs, or gallops.

Respiratory: CTAB, no wheezes, rales, or rhonchi.

Gastrointestinal: Soft, non-tender, non-distended, normoactive bowel sounds. No hepatosplenomegaly.

Musculoskeletal:

• Right knee: Mild crepitus with passive ROM, medial joint line tenderness to palpation. No effusion, erythema, or warmth. Flexion 130 degrees, extension full. McMurray test negative, anterior and posterior drawer tests negative, valgus/varus stress tests stable.

Skin: 4 mm erythematous, hyperkeratotic papule on R dorsal forearm. No suspicious pigmented lesions noted on total body skin exam.

Neurologic: Alert and oriented x3. CN II-XII intact. Motor 5/5 and sensation intact in upper and lower extremities bilaterally. Gait normal.

Psychiatric: Cooperative, appropriate mood and affect.

Labs / Imaging / Diagnostic Tests

1. Lipid panel (10/04/2025): Total cholesterol 185 mg/dL, HDL 52 mg/dL, LDL 112 mg/dL (down from 145 mg/dL in 2024), Triglycerides 105 mg/dL. Repeat in 1 yr.
2. CMP (10/04/2025): Glucose 92 mg/dL, BUN 14 mg/dL, Cr 0.8 mg/dL, eGFR > 60 mL/min, Na 140 mmol/L, K 4.2 mmol/L, AST 22 U/L, ALT 19 U/L. Repeat in 1 yr.
3. CBC (10/04/2025): WBC 6,200 /uL, Hgb 13.8 g/dL, Plt 245,000 /uL.

Assessment & Plan

1. Preventive Care Z00.00

Assessment: 52-year-old postmenopausal female presents for her annual wellness visit. She remains active and adheres to a healthy diet. Up to date on cervical and colorectal cancer screenings. Due for routine breast cancer screening and annual laboratory surveillance.

Plan

• Order bilateral screening mammogram to be completed within 1 mo.
• Order annual fasting lipid panel, CMP, and CBC for next visit in 12 mos.
• Administered influenza vaccine today.
• Continue colecalciferol 1,000 IU PO daily and calcium citrate 500 mg PO daily.
• RTC in 1 yr for next AWV.

2. Right knee pain M25.561

Assessment: Insidious onset of right medial knee pain with crepitus and joint line tenderness, lacking mechanical locking or instability on exam. Since onset 3 mos ago, symptoms have been mildly responsive to PRN paracetamol. Differential diagnosis from most to least likely includes: 1) Primary osteoarthritis of the right knee, 2) Medial meniscal degeneration, and 3) Pes anserine bursitis.

Plan

• Order standing AP, lateral, and sunrise view X-rays of the R knee.
• Initiate diclofenac sodium (Voltaren®) 1% topical gel, apply 4 g to R knee QID PRN pain.
• Refer to physical therapy for quadriceps strengthening and low-impact conditioning.
• Follow up in 4-6 wks if symptoms do not improve.

3. Essential hypertension I10

Assessment: Chronic essential hypertension remains well-controlled on current monotherapy without adverse medication effects or end-organ symptoms. Office and home BP readings are at goal.

Plan

• Continue lisinopril (Prinivil®) 10 mg PO daily.
• Continue low-sodium Mediterranean diet and regular aerobic exercise as tolerated.

4. Actinic keratosis L57.0

Assessment: Solitary 4 mm hyperkeratotic papule on sun-exposed right dorsal forearm, clinically consistent with actinic keratosis. Treated in office today via cryotherapy.

Plan

• Performed liquid nitrogen cryotherapy to R forearm lesion today.
• Advised daily broad-spectrum SPF 30+ sunscreen application.
• Continue annual full-body skin exams with Dermatology.

Procedure Note

Patient Name: Evelyn Vance

Date of Procedure: 14/04/2026

Procedure Performed: Cryotherapy of premalignant skin lesion (1 lesion)

Indication: Destruction of actinic keratosis on right dorsal forearm

Pre-Procedure Diagnosis: Actinic keratosis (L57.0)

Post-Procedure Diagnosis: Actinic keratosis (L57.0)

Details of Procedure

Consent: Informed consent was obtained, including discussion of risks, benefits, and alternatives.

Preparation: Lesion on the right dorsal forearm was identified and cleansed with a 70% isopropyl alcohol prep pad. No local anesthetic required.

Procedure Steps: Liquid nitrogen was applied to the 4 mm hyperkeratotic papule using a cryogun spray technique in two freeze-thaw cycles of 10 seconds each, achieving a 2 mm halo of freeze around the lesion margin.

Findings: 4 mm erythematous, scaly papule on right dorsal forearm; appropriate white frosting and subsequent erythematous thaw observed.

Complications: None.

Post-Procedure Care

Patient tolerated the procedure well.

Post-procedure monitoring: Observed in clinic for 10 mins post-procedure; mild localized erythema noted as expected. Advised patient to expect blistering and crusting over the next 7-14 days, and instructed to wash daily with mild soap and water, applying white petrolatum (Vaseline®) daily until healed. Instructed to call clinic for signs of infection (increasing redness, pus, severe pain).

Follow-up plan: Monitor lesion site for complete resolution over 4 wks; return to clinic or see Dermatology if lesion persists or recurs.

Medications Administered

Liquid nitrogen applied topically.