​‌‍‌‍‍I. Chief complaint: Patient here for physical exam, Pap smear and lab results II. History of the Present Illness: 55-year-old female here for physical exam. H/o total hysterectomy 2009 and left breast cancer in 2006. Patient reports of left TMJ pain that nothing has been done. MRI was inconclusive. Requesting for Ibuprofen for TMJ pain. Last colonoscopy was in 2014 and it was normal. No other concerns at this time. III. Past History; Breast cancer 2006 Arthritis Hyperlipidemia IV. GYN History: Sexual active Last Pap smear 2011 Last mammogram 2014 Birth Control: None Hysterectomy 2011 V. OB History: Total Pregnancies 7 Total living 6 Miscarriage 1 C section 0 VI. Family History: Mother: Deceased Father: Alive . VII. Social History: no smoking. No alcohol, no drugs VIII. Allergies: Vicodin: anaphylaxis IX. Medication History/Review: Taking Ibuprofen 800mg BID Constitutional: Denies fever, chills, loss of appetite or change in weight 1. HENT: Denies voice changes, denies ear pain, denies ringing in the ears, sore throat, hearing admits difficulty swallowing 2. Eyes: denies eye pain, denies blurry vision 3. Cardiovascular: Denies chest pain and palpitations 4. Respiratory: denies cough, no wheezing and shortness of breath. 5. Gastrointestinal: denies abdominal pain. Denies change in bowel habits 6. Genitourinary: denies difficult urination or discharge. 7. Musculoskeletal: denies painful joint pain or swelling​‌‍‌‍‍‌‍‌‌‌‍‍‍‍‌‌‌‌‌​8. Neurological: denies difficulty speaking and irritability 9. Skin: denies lesion, skin oozing, eczema or rash. B. OBJECTIVE: A. Vital Signs: Temp 98.3 F, HR 70 bpm, BP 109/68mm Hg, R18, O2 sat 96%, BMI 25 B. Physical Examination 1. Constitutional/General: In no acute distress, well develop, well nourished 2 Ears: Normal left ear, pearly gray tympanic membrane 3. Nose: Nares patent. 4. Mouth/lip- Moist mucosa Throat: no exudate or erythema 6.Eyes: pink conjunctiva, PERRLA, 7. Neck: Neck supple, full ROM, no cervical lymphadenopathy 8. Cardiovascular: S1, S2 normal, no murmur, Bradycardia 9. Respiratory: Lungs clear to auscultation bilaterally, no wheezing, rales 10. Breast: Scar on the left lateral breast 11. Abdomen: soft, nontender, nondistended, no guarding or rigidity, 12. Genitourinary: no difficult or painful urination 13. Musculoskeletal: no swelling or deformity 14. Neurological: alert and oriented. 15. Skin/Integumentary: no rash, no oozing or lesion. C. ASSESSMENT: Diagnosis of the case (use ICD 10 coding guidelines) Annual Physical Exam – Z00.00 TMJ (temporomandibular joint disorder) – M26.60 D. PLAN 1. Diagnostic Plan: Mammogram screening, MRI of TMJ Labs: Urine dipstick now, pap test screening , CBC, CMP, LIPID PANEL, HEPATIC FUNCTION PANEL, TSH, Medication: Start ibuprofen tablet 600 mg Referral: None 2. Follow up: 2weeks for lab review 4. Patient Education/Health Promotion HEALTH MAINTENACE Diet and exercise discussed with patient Lifestyle modification Please use the case attached for this case study a sample was upl​‌‍‌‍‍‌‍‌‌‌‍‍‍‍‌‌‌‌‌​oaded

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