IM – HTN, DM | CLINIBORG

new patient existing patient history provided by patient history provided by family member SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA

CC:

MEDICATIONS: nitrates b-blocker insulin metformin SGLT2 GLP1 DPP4 ASA Plavix anticoagulants

REGIMEN COMPLIANCE: taking as prescribed not taking as prescribed reports no side effects reports side effects demonstrates knowledge of medications/reasons/dosages unable to name medications/reasons/dosages medication list/labels/containers available for review medication list/labels/containers not available for review reports checking BS at home reports not checking BS at home insulin/BS log available for review insulin/BS log not available for review reports checking BP at home reports not checking BP at home BP record available for review BP record unavailable for review

RECENT HISTORY: non-contributory visit to ER/UC hospitalization/surgery/procedure new medications antibiotic use diagnostic study

PMH/Comorbidities: HTN LVH, CHF aneurysm atrial fibrillation pacemaker CAD,MI angio/stent CABG CVA,TIA PAD ED PE,DVT carotid endarterectomy BMI greater than 30 dyslipidemia diabetes retinopathy microalbuminuria GFR less than 60 COPD snoring,sleep apnea

CV PROCEDURES - completed: EKG stress test cardiac ECHO LE U/S ABI calcium score

PREVENTIVE SERVICES: [+] completed [-] not completed/indicated
annual dilated eye exam annual diabetic foot exam annual microalbumin annual FOBT colonoscopy DEXA LDCT AAA Doppler PAP mammogram PSA DRE

VACCINATION: [+] completed [-] not completed/indicated
flu pneumo completed DT shingles

SCREENING & COUNSELING: functional ability/safety depression alcohol misuse tobacco use obesity STI completed today & discussed with patient deferred

REVIEW OF SYSTEMS: negative except as stated in HPI
General:

HEENT:

CV:

Pulmonary:

GI:

GU:

MSK:

Neurologic:

Psychiatric:

Dermatologic:

Endocrine:

Hematologic/lymphatic:

OUTSIDE RESULTS: imaging studies laboratory studies specialty consults

OFFICE DIAGNOSTICS: EKG RBS normal non-specific changes no acute findings abnormal discussed with patient/SO

General: well-appearing normal built heavy built lean well-nourished emaciated frail no signs of discomfort visible while sitting in chair no signs of discomfort visible while ambulating & getting on/off exam table ill-appearing tired-looking short of breath diaphoretic good hygiene disheveled bizarre clothes body odor drowsy appears impaired slumped no ambulation aids/DME ambulation requires walker ambulation requires cane ambulation requires wheelchair wearing cervical collar wearing lumbar support wearing extremity brace

Head/Face: normocephalic, atraumatic normal hair distribution symmetrical face CN grossly intact plethoric face alopecia facial droop

Eyes: clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact cornea(s) clear glasses contacts conjunctival injection epiphora conjunctival exudate allergic shiners dysconjugate gaze

Ears: symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or discharge TMs normal in appearance

Nose: nares patent bilaterally septum midline no facial tenderness mucosa pink & moist swollen & boggy mucosa mucosal congestion clear discharge yellow discharge crusty discharge rhinophyma

Mouth: tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions upper denture lower denture poor dentition oral ulcers gum swelling tooth decay

Throat: normal voice, no stridor patent pharynx w/o swelling or exudates uvula midline hoarseness vesicles on soft palate petechiae on soft palate pharyngeal erythema w/o exudates

Neck: symmetric with free painless ROM and no masses supple no LAD no bruit or JVD anterior LAD posterior LAD thyroid enlargement nuchal tenderness

Chest/Lungs: normal work of breathing, symmetrical chest expansion clear and equal breath sounds bilaterally chest wall atraumatic and non-tender no axillary or supraclavicular LAD SOB decreased bilaterally wheezing crackles

CV: regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm systolic murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen: normal visual inspection, no distension normal active bowel sounds soft non-tender no bruit auscultated over AA and renal arteries protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG hypoactive bowel sounds hyperactive bowel sounds direct non-rebound tenderness colostomy in situ deferred

GU: no suprapubic tenderness no CVAT bilaterally Foley in situ normal external genitalia no inguinal LAD testicular tenderness urethral discharge verrucous papules vesicles crusted lesions deferred

MSK: no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature & ROM in C- & L-spine for patient’s age non-tender C-spine with good ROM non-tender L-spine with good ROM strength, tone, & bulk symmetrical & grossly intact kyphosis paraspinal muscle spasm C-spine tenderness & DROM neck pain with active motion paracervical muscle spasm old surgical scar(s) in C-spine trapezius tenderness L-spine tenderness reduced painful ROM in lumbar region paraspinal muscle spasm trigger points in L-spine old surgical scar(s) in L-spine heel-walk & toe-walk without difficulty negative seated SLR positive seated SLR

Skin: grossly intact, no rashes no bruises normal turgor tattoos body piercings poor turgor dry sweaty

Neuro: normal concentration and attention memory grossly intact balance & coordination grossly intact ambulates w/o limp or alteration in gait extremities strong w/o atrophy no gross motor deficits sensation symmetrical & grossly intact no involuntary movements or tremor antalgic gait wide gait shuffling gait diffuse numbness w/o dermatomal pattern dystonia tardive dyskinesia tics

Speech/Vocalization: normal for age clear & coherent slurred mumbling to self monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured groaning sighing crying perseveration flight of ideas repetitive questions self-depreciating statements repetitive statements of impending doom repetitive non-health related/financial concerns personal safety concerns suicidal ideation/threats insisting on particular medication, test, referral, or accommodation raising voice defensive argumentative cursing, swearing previous providers/staff criticisms verbal threats sexual remarks racist remarks

Behavior/Psychomotor Activity: calm, pleasant, respectful cooperative with history & exam guarded anxious irritable frustrated labile agitated hostile forceful pacing fidgeting picking skin twirling hair cracking knuckles grimacing, furrowing eyebrows tightening jaw breathing hard intense staring threatening gestures fist-clenching withdrawn flat affect bradykinetic indifferent appears to be responding to internal psychotic process

A/P:

2ry HTN: cortisol|renal failure|aldosterone|renal artery stenosis

ORDER - RX: none OTC electronic paper given to MA to be transmitted to pharmacy

ORDER - LABS: none CBC CMP TSH A1C Lipids PSA FOBT/FIT UA HIV, RPR, HCV, GC, CT UDS

ORDER - IMAGING: none X-ray US MRI

ORDER - REFERRALS: none cardiology endocrinology

ORDER - FORMS: none excuse clearance restrictions

STAFF INSTRUCTIONS: none obtain hospital/ER discharge report obtain specialty report obtain imaging report obtain laboratory report remind patient to always bring all medication containers to visit

REVIEWED/DISCUSSED: exam findings, POC, risks of/benefits of/alternatives to proposed POC, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services, medicationS previous visits laboratory/diagnostic studies specialty reports hospital records alcohol cessation smoking cessation weight reduction/exercise salt restriction carbs restriction appropriate follow up medication compliance bringing all medications/labels to all visits home BP checks home BS checks daily weights controlling chronic conditions age-appropriate screening and immunization annual eye exam cognitive restructuring in managing chronic conditions symptom exacerbation through rebound mechanism risks of respiratory depression with polypharmacy

PLAN OF CARE: patient/family verbalized understanding of & agreement with POC patient/family did not agree with my POC – will seek second opinion/further care elsewhere

DISCHARGE CONDITION/SAFETY: improved stable unchanged no safety concerns at this time safety concerns d/t depressed agitated mood safety concerns d/t impulsiveness safety concerns d/t hostile temper safety concerns d/t past attempts safety concerns d/t current suicidal verbalization

FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx
RTC 24 hours RTC 2-3 days RTC 1 week RTC 4 weeks medication review f/u acute episode f/u labs f/u imaging f/u referral

DISPOSITION: home referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left clinic before being discharged asked to leave clinic

depression

risk

diabetes

BARRIERS TO CARE: none noted at this time incomplete history d/t poor effort incomplete history d/t cognitive changes incomplete history d/t distress/affect incomplete history d/t language barrier vague shifting complaints history not supported by objective findings supporting documentation unavailable incomplete exam d/t safety concerns poor cooperation with exam multiple comorbidities polypharmacy poor compliance with POC intolerance of/therapeutic failure on multiple meds preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others lack of motivation negative attitude to diagnostic impression & proposed tx lack of interest in nonpharmacologic therapies psychiatric comorbidity h/o alcohol/substance abuse victim of abuse social/cultural barriers altered mental status affect hostile/disruptive behavior

IM – HTN, DM

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