SUBJECTIVE: A 35-year-old white female here for well-woman exam. She is (1)________, P2. None in the past year secondary to Depo-Provera use and a history of (2)________. Patient is sexually active with one partner. She is married. Last (3)________ 1 year ago, within normal limits. The patient has not had a baseline (4)________ done. She does self-breast exams sporadically. No history of uterine,

(5)________, or breast cancer of herself or her family. Patient is currently, as noted, on Depo-Provera. A negative uterine pregnancy test was done today, and a prescription was filled. The patient has her Depo-Provera injection with her.

OBJECTIVE: Neck: Thyroid nonpalpable. Breasts: Symmetrical, mild (6)________ changes bilaterally, nontender without masses, no skin changes, no nipple discharge. Genitalia: (7)________ within normal limits, vagina normal, cervix normal in appearance and nontender. Pap done without incident. Bimanual: (8)________ nontender without fullness, (9)________ midline, anteverted, and nontender without mass. Rectal exam was not done.

LABORATORY DATA: (10)________ within normal limits.

ASSESSMENT AND PLAN: Health maintenance. Pap done. Recommend annual Pap. Patient referred for baseline mammogram. Self-breast exam every month recommended. Depo-Provera shot given. Recommend negative pregnancy test prior to every Depo-Provera injection. Follow up as needed.

1. G2
2. STDs
3. Pap
4. mammogram
5. ovarian
6. fibrous
7. BUS
8. Adnexa
9. corpus
10. Urinalysis