cnramsey
Guest
DOS was 2/11/2021
Primary Care Provider XX
Accompanied by XX
Visit Type: Physical Exam
Chief Complaint: Annual PE
History of Present Illness:
XX year old with hx of celiac disease. had Covid 19 in December and has not felt right since. fatigued a lot . episodes of feeling worse. some abd pain/cramping when makes wrong diet choices though that is not real frequent. lost 10 lbs with covid 19 and difficulty regaining wt.
non smoker. denies etoh or drug use
no bowel changes.
deneis dysphagia and says appetitie is ok
does not routinely exercise
persistant difficulty sleeping
Problem List Changes:
Added new problem of Fatigue (ICD-780.79) (ICD10-R53.83) - Signed
Added new problem of Hypoglycemia (ICD-251.2) (ICD10-E16.2)
Assessed Hypoglycemia as new
Assessed Celiac disease as unchanged
Assessed Fatigue as unchanged
Medical History: (Reviewed and Updated)
Sleep difficulty
Celiac disease
Review of Systems:
General: wt down
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GU: no urinary symptoms
Psychiatric: deniess depression or anxiety
Vital Signs:
REMOVED
Physical Exam:
General: Well developed, well groomed, in no acute distress.
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Abdomen: Soft/nontender; No guarding or rebound; Bowel sounds present.
Extremity: No cyanosis or edema.
Skin: No rashes or atypical lesions.
Psych: Alert and oriented.
Assessment and Plan:
• HYPOGLYCEMIA (ICD-251.2) (ICD10-E16.2) New
hypoglycemia on labs and had eaten couple hours prior to labs.
likely recurrent hypoglycemia from episodes discussed.
discussed frequent higher protein meals, snacking every 3 -4 hours to avoid .
reeval or consider checking blood sugars if recurrent
• CELIAC DISEASE (ICD-579.0) (ICD10-K90.0) Unchanged
stable with gluten restrictions
• FATIGUE (ICD-780.79) (ICD10-R53.83) Unchanged
post covid has been challenging to return to baseline.
labs other then hypoglycemia are normal. will work on better sleep hygeine. melatonin nightly. reeval if not improving.
Orders:
Comprehensive Metabolic Panel [CMP] DX attached to order R53.83
Hemogram (CBC no diff) [HGMP] DX attached to order R53.83
TSH reflex to Free T4 [TSH-R] DX attached to order R53.83
Vitamin D [VDOH] DX attached to order K90.0
Sed Rate [SR] DX attached to order R53.83
Primary Care Provider XX
Accompanied by XX
Visit Type: Physical Exam
Chief Complaint: Annual PE
History of Present Illness:
XX year old with hx of celiac disease. had Covid 19 in December and has not felt right since. fatigued a lot . episodes of feeling worse. some abd pain/cramping when makes wrong diet choices though that is not real frequent. lost 10 lbs with covid 19 and difficulty regaining wt.
non smoker. denies etoh or drug use
no bowel changes.
deneis dysphagia and says appetitie is ok
does not routinely exercise
persistant difficulty sleeping
Problem List Changes:
Added new problem of Fatigue (ICD-780.79) (ICD10-R53.83) - Signed
Added new problem of Hypoglycemia (ICD-251.2) (ICD10-E16.2)
Assessed Hypoglycemia as new
Assessed Celiac disease as unchanged
Assessed Fatigue as unchanged
Medical History: (Reviewed and Updated)
Sleep difficulty
Celiac disease
Review of Systems:
General: wt down
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GU: no urinary symptoms
Psychiatric: deniess depression or anxiety
Vital Signs:
REMOVED
Physical Exam:
General: Well developed, well groomed, in no acute distress.
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Abdomen: Soft/nontender; No guarding or rebound; Bowel sounds present.
Extremity: No cyanosis or edema.
Skin: No rashes or atypical lesions.
Psych: Alert and oriented.
Assessment and Plan:
• HYPOGLYCEMIA (ICD-251.2) (ICD10-E16.2) New
hypoglycemia on labs and had eaten couple hours prior to labs.
likely recurrent hypoglycemia from episodes discussed.
discussed frequent higher protein meals, snacking every 3 -4 hours to avoid .
reeval or consider checking blood sugars if recurrent
• CELIAC DISEASE (ICD-579.0) (ICD10-K90.0) Unchanged
stable with gluten restrictions
• FATIGUE (ICD-780.79) (ICD10-R53.83) Unchanged
post covid has been challenging to return to baseline.
labs other then hypoglycemia are normal. will work on better sleep hygeine. melatonin nightly. reeval if not improving.
Orders:
Comprehensive Metabolic Panel [CMP] DX attached to order R53.83
Hemogram (CBC no diff) [HGMP] DX attached to order R53.83
TSH reflex to Free T4 [TSH-R] DX attached to order R53.83
Vitamin D [VDOH] DX attached to order K90.0
Sed Rate [SR] DX attached to order R53.83