perkins05
Expert
Associated Diagnoses: Anxiety Disorder; Chronic Tension Headaches; Degenerative disc disease, cervical; Depressive Disorder; Essential Hypertension, Benign; Hyperlipidemia LDL Goal < 100; Need for Shingles Vaccine; Prediabetes; Screening for Malignant Neoplasms of Colon; Screening for Malignant Neoplasms of Prostate; Screening for Malignant Neoplasms of Testis; Well man health examination; Neoplasm of Uncertain Behavior
Report Summary
1. Neurologic:
Alert, Oriented, No focal defects.
Visit Information
Accompanied by: Spouse.
CHIEF COMPLAINT
routine check up
Pt here for f/u HTN, hyperlipidemia, prediabetes, depression with anxiety, tension headaches, and cervical degenerative disc disease. Reports compliance with meds. Pt had fasting labs drawn recently. Pt also here for routine physical, including prosate exam.
Review of Systems
Constitutional: Pt has lost 8.6 pounds since 12/2011 due to eating healthier..
Respiratory: No shortness of breath.
Cardiovascular: Home BP readings have been running 120's to 140's over 60's to 80's with most readings running around 130/70., No chest pain.
Genitourinary: No nocturia. No urinary hesitancy., No change in urine stream.
Integumentary: Pt said skin lesion on right cheek developed a small area of pus on it recently which drained. Pt cleaned it and applied neosporin which resolved the pus. Pt says the bump is still on right cheek but bump itself has not changed and looks the same as it has for years..
Health Status
NKDA (No reactions were documented)
Medications: (Selected).
Prescriptions
Ordered
Bystolic 10 mg oral tablet: 1 tab(s) ( 10 mg ), po, daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Exforge 5 mg-160 mg oral tablet: 1 tab(s), po, daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Fiorinal 325 mg-50 mg-40 mg oral tablet: 1 tab(s), PO, bid, PRN: | for headache, # 60 tab(s), 1 Refill(s), Type: Maintenance
Flexeril 10 mg oral tablet: See Instructions, Instructions: Take 0.5 to 1 whole tab PO qhs, PRN: for muscle spasm, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Flexeril 10 mg oral tablet: See Instructions, Instructions: Take 0.5 to 1 whole tab PO qhs, PRN: for spasm or muscle pain, # 30 tab(s), 0 Refill(s), Type: Soft Stop, Pharmacy: Majoria Drugs - Terrytown LA
Lipitor 20 mg oral tablet: 1 tab(s) ( 20 mg ), po, hs, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Zoloft 50 mg oral tablet: 1 tab(s) ( 50 mg ), PO, Daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Documented Medications
Documented
Allegra 180 mg oral tablet: 1 tab(s) ( 180 mg ), po, daily, PRN: as needed for allergy symptoms, tab(s), 0 Refill(s), Type: Maintenance
Aspir 81 oral enteric coated tablet: 1 tab(s) ( 81 mg ), po, daily, tab(s), 0 Refill(s), Type: Maintenance
psyllium: See Instructions, Instructions: one tablet by mout twice a day per Dr Kedia, 0 Refill(s), Type: Maintenance
Problem list: .
All Problems (Selected)
Anxiety Disorder / ICD-9-CM 300.00 / Confirmed
Chronic Tension Headaches / ICD-9-CM 307.81 / Confirmed
Degenerative disc disease, cervical / ICD-9-CM 722.4 / Confirmed
Depressive Disorder / ICD-9-CM 311 / Confirmed
Diverticulosis of Colon (Without Mention of Hemorrhage) / ICD-9-CM 562.10
Erectile dysfunction
Essential Hypertension, Benign / ICD-9-CM 401.1 / Confirmed
Hyperlipidemia LDL Goal < 100 / ICD-9-CM 272.4 / Confirmed
Impotence of Organic Origin / ICD-9-CM 607.84
Pre-diabetes
Histories
Past Medical History: .
No active or resolved past medical history items have been selected or recorded.
Family History: .
No family history items have been selected or recorded.
Procedure history: .
Fecal occult blood screening (SNOMED CT 1217344014) in 2011 at 67 Years.
Rectal examination (SNOMED CT 2471738015) in 2011 at 67 Years.
PSA - Prostate specific antigen (SNOMED CT 1218846017) in 2011 at 67 Years.
Examining eye (SNOMED CT 486400019) in 2011 at 67 Years.
Comments:
11/7/2011 10:07 AM -
see Dr Bloom for eye care
Colonoscopy (SNOMED CT 122490017) in 2009 at 65 Years.
Comments:
11/7/2011 10:05 AM
f/u colonoscopy 5 years
stress test in 2007 at 63 Years.
Comments:
11/7/2011 10:08 AM -
pt says he had a stress test with the past few years and was told was good
neck surgery for disc disease in 1999 at 55 Years.
R inguinal hernia repair in 1900.
Social History: .
Alcohol Assessment
Never
Tobacco Assessment
Never
Substance Abuse Assessment
Never
Physical Examination
VS/Measurements
Vital Signs
7/3/2012 8:40 AM CDT
Temperature Oral
97.2 DegF
Peripheral Pulse Rate
61 bpm
Pulse Site
Apical artery
Respiratory Rate
18 br/min
Systolic Blood Pressure
134 mmHg
Diastolic Blood Pressure
80 mmHg
Mean Arterial Pressure
98 mmHg
BP Site
Left arm
Pain Present
No
, Measurements from flowsheet : Measurements
7/3/2012 8:40 AM CDT
Height
70 in
Weight
192.2 lb
BSA
2.07 m2
Body Mass Index
27.57 kg/m2
Ht/Wt Measurement Refused by Patient?
No
Documented vital signs: Blood Pressure ( Systolic 144 mmHg, Diastolic 78 mmHg )
General: Alert and oriented, No acute distress.
Eye: Pupils are equal, round and reactive to light, Extraocular movements are intact, Normal conjunctiva, + eyeglasses.
HENT: Tympanic membranes are clear, Oral mucosa is moist, No pharyngeal erythema.
Neck: Supple, Non-tender, No carotid bruit, No lymphadenopathy, No thyromegaly.
Respiratory: Lungs are clear to auscultation.
Cardiovascular: Normal rate, Regular rhythm, No murmur.
Breast: No mass, No tenderness, No discharge.
Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.
Genitourinary: No costovertebral angle tenderness, No scrotal tenderness, No inguinal tenderness, No urethral discharge, No lesions, Pt has an approx. 45gm, smooth, symmetrical, non-tender prostate gland..
Lymphatics: No lymphadenopathy neck, axilla, groin.
Musculoskeletal: Pt has trace pretibial edema bilaterally.
.
Integumentary: Pt has an approx. 0.5 x 0.5cm smooth, raised papule with spotty brown color on right cheek. No tenderness to palpation, induration, or drainage of fluid. Papule is slightly fluctulent..
Neurologic: Alert, Oriented, No focal defects.
Cognition and Speech: Oriented, Speech clear and coherent, Functional cognition intact.
Psychiatric: Cooperative, Appropriate mood & affect.
Review / Management
Results review: Lab results : Laboratory,
All Results: 7/3/2012 9:32 AM CDT Occult Bld Stl Negative .
ECG interpretation: EKG with sinus rhythm, rate 57.
Impression and Plan
Diagnosis
Anxiety Disorder (ICD9 300.00).
Neoplasm of Uncertain Behavior (ICD9 238.9).
Chronic Tension Headaches (ICD9 307.81).
Degenerative disc disease, cervical (ICD9 722.4).
Depressive Disorder (ICD9 311).
Essential Hypertension, Benign (ICD9 401.1).
Hyperlipidemia LDL Goal < 100 (ICD9 272.4).
Need for Shingles Vaccine (ICD9 V05.4).
Prediabetes (ICD9 790.29).
Screening for Malignant Neoplasms of Colon (ICD9 V76.51).
Screening for Malignant Neoplasms of Prostate (ICD9 V76.44).
Screening for Malignant Neoplasms of Testis (ICD9 V76.45).
Well man health examination (ICD9 V70.0).
Plan: BP usually good. I reviewed pt's home BP readings today. BP better when nurse checked it but elevated some when I checked it. Continue current BP meds and continue monitoring BP. Pt takes fioricet about 1-3 times per month. Headache usually comes on if he sleeps in an uncomfortable position, aggravating his neck pain which then leads to tension headache. Pt seldomly takes flexeril. Plan shave biopsy of skin lesion on right cheek within next month. Pt says he cannot have biopsy until next month because his wife is going to have cataract surgery on one eye in 2 days, followed by cataract surgery on other eye about 2 weeks later. Depression and anxiety are well-controlled. Maintain low fat, low chol, low CHO diet to help keep cholesterol controlled and reduce likelihood of developing DM. Hyperlipidemia is under excellent control.
.
Orders
Orders.
In Office Patient Care:
Zostavax ORDER SET (Ordered)
Pharmacy:
zoster vaccine live subcutaneous injection (Ordered): 0.65 mL, subcutaneous, once, # 0.65 mL, 0 Refill(s), Type: Soft Stop, Pharmacy: Majoria Drugs - Terrytown LA
Charges:
90736 zoster shingles vaccine live subcutaneous (Task/Charge) (Ordered): Quantity: 1
Orders.
Pharmacy:
Zoloft 50 mg oral tablet (Ordered): 1 tab(s) ( 50 mg ), PO, Daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: Majoria Drugs - Terrytown LA
Lipitor 20 mg oral tablet (Ordered): 1 tab(s) ( 20 mg ), po, hs, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: Majoria Drugs - Terrytown LA
Exforge 5 mg-160 mg oral tablet (Ordered): 1 tab(s), po, daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: Majoria Drugs - Terrytown LA
Lipitor 20 mg oral tablet (Discontinued)
Exforge 5 mg-160 mg oral tablet (Discontinued)
Zoloft 50 mg oral tablet (Discontinued)
Orders.
Charges:
82270 blood occult peroxidase actv qual feces 1 deter (Task/Charge) (Ordered): Quantity: 1
93000 ecg routine ecg w/least 12 lds w/i+r (Task/Charge) (Ordered): Quantity: 1
Orders.
Charges (Evaluation and Management):
Return to Clinic (Request) (Ordered): RFV: for biopsy of skin lesion on right cheek or sooner prn, Return in 1 month
Return to Clinic (Request) (Ordered): RFV: for f/u chronic medical problems or sooner prn, Return in 4 months
Report Summary
1. Neurologic:
Alert, Oriented, No focal defects.
Visit Information
Accompanied by: Spouse.
CHIEF COMPLAINT
routine check up
Pt here for f/u HTN, hyperlipidemia, prediabetes, depression with anxiety, tension headaches, and cervical degenerative disc disease. Reports compliance with meds. Pt had fasting labs drawn recently. Pt also here for routine physical, including prosate exam.
Review of Systems
Constitutional: Pt has lost 8.6 pounds since 12/2011 due to eating healthier..
Respiratory: No shortness of breath.
Cardiovascular: Home BP readings have been running 120's to 140's over 60's to 80's with most readings running around 130/70., No chest pain.
Genitourinary: No nocturia. No urinary hesitancy., No change in urine stream.
Integumentary: Pt said skin lesion on right cheek developed a small area of pus on it recently which drained. Pt cleaned it and applied neosporin which resolved the pus. Pt says the bump is still on right cheek but bump itself has not changed and looks the same as it has for years..
Health Status
NKDA (No reactions were documented)
Medications: (Selected).
Prescriptions
Ordered
Bystolic 10 mg oral tablet: 1 tab(s) ( 10 mg ), po, daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Exforge 5 mg-160 mg oral tablet: 1 tab(s), po, daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Fiorinal 325 mg-50 mg-40 mg oral tablet: 1 tab(s), PO, bid, PRN: | for headache, # 60 tab(s), 1 Refill(s), Type: Maintenance
Flexeril 10 mg oral tablet: See Instructions, Instructions: Take 0.5 to 1 whole tab PO qhs, PRN: for muscle spasm, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Flexeril 10 mg oral tablet: See Instructions, Instructions: Take 0.5 to 1 whole tab PO qhs, PRN: for spasm or muscle pain, # 30 tab(s), 0 Refill(s), Type: Soft Stop, Pharmacy: Majoria Drugs - Terrytown LA
Lipitor 20 mg oral tablet: 1 tab(s) ( 20 mg ), po, hs, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Zoloft 50 mg oral tablet: 1 tab(s) ( 50 mg ), PO, Daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: RightSource Rx
Documented Medications
Documented
Allegra 180 mg oral tablet: 1 tab(s) ( 180 mg ), po, daily, PRN: as needed for allergy symptoms, tab(s), 0 Refill(s), Type: Maintenance
Aspir 81 oral enteric coated tablet: 1 tab(s) ( 81 mg ), po, daily, tab(s), 0 Refill(s), Type: Maintenance
psyllium: See Instructions, Instructions: one tablet by mout twice a day per Dr Kedia, 0 Refill(s), Type: Maintenance
Problem list: .
All Problems (Selected)
Anxiety Disorder / ICD-9-CM 300.00 / Confirmed
Chronic Tension Headaches / ICD-9-CM 307.81 / Confirmed
Degenerative disc disease, cervical / ICD-9-CM 722.4 / Confirmed
Depressive Disorder / ICD-9-CM 311 / Confirmed
Diverticulosis of Colon (Without Mention of Hemorrhage) / ICD-9-CM 562.10
Erectile dysfunction
Essential Hypertension, Benign / ICD-9-CM 401.1 / Confirmed
Hyperlipidemia LDL Goal < 100 / ICD-9-CM 272.4 / Confirmed
Impotence of Organic Origin / ICD-9-CM 607.84
Pre-diabetes
Histories
Past Medical History: .
No active or resolved past medical history items have been selected or recorded.
Family History: .
No family history items have been selected or recorded.
Procedure history: .
Fecal occult blood screening (SNOMED CT 1217344014) in 2011 at 67 Years.
Rectal examination (SNOMED CT 2471738015) in 2011 at 67 Years.
PSA - Prostate specific antigen (SNOMED CT 1218846017) in 2011 at 67 Years.
Examining eye (SNOMED CT 486400019) in 2011 at 67 Years.
Comments:
11/7/2011 10:07 AM -
see Dr Bloom for eye care
Colonoscopy (SNOMED CT 122490017) in 2009 at 65 Years.
Comments:
11/7/2011 10:05 AM
f/u colonoscopy 5 years
stress test in 2007 at 63 Years.
Comments:
11/7/2011 10:08 AM -
pt says he had a stress test with the past few years and was told was good
neck surgery for disc disease in 1999 at 55 Years.
R inguinal hernia repair in 1900.
Social History: .
Alcohol Assessment
Never
Tobacco Assessment
Never
Substance Abuse Assessment
Never
Physical Examination
VS/Measurements
Vital Signs
7/3/2012 8:40 AM CDT
Temperature Oral
97.2 DegF
Peripheral Pulse Rate
61 bpm
Pulse Site
Apical artery
Respiratory Rate
18 br/min
Systolic Blood Pressure
134 mmHg
Diastolic Blood Pressure
80 mmHg
Mean Arterial Pressure
98 mmHg
BP Site
Left arm
Pain Present
No
, Measurements from flowsheet : Measurements
7/3/2012 8:40 AM CDT
Height
70 in
Weight
192.2 lb
BSA
2.07 m2
Body Mass Index
27.57 kg/m2
Ht/Wt Measurement Refused by Patient?
No
Documented vital signs: Blood Pressure ( Systolic 144 mmHg, Diastolic 78 mmHg )
General: Alert and oriented, No acute distress.
Eye: Pupils are equal, round and reactive to light, Extraocular movements are intact, Normal conjunctiva, + eyeglasses.
HENT: Tympanic membranes are clear, Oral mucosa is moist, No pharyngeal erythema.
Neck: Supple, Non-tender, No carotid bruit, No lymphadenopathy, No thyromegaly.
Respiratory: Lungs are clear to auscultation.
Cardiovascular: Normal rate, Regular rhythm, No murmur.
Breast: No mass, No tenderness, No discharge.
Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.
Genitourinary: No costovertebral angle tenderness, No scrotal tenderness, No inguinal tenderness, No urethral discharge, No lesions, Pt has an approx. 45gm, smooth, symmetrical, non-tender prostate gland..
Lymphatics: No lymphadenopathy neck, axilla, groin.
Musculoskeletal: Pt has trace pretibial edema bilaterally.
.
Integumentary: Pt has an approx. 0.5 x 0.5cm smooth, raised papule with spotty brown color on right cheek. No tenderness to palpation, induration, or drainage of fluid. Papule is slightly fluctulent..
Neurologic: Alert, Oriented, No focal defects.
Cognition and Speech: Oriented, Speech clear and coherent, Functional cognition intact.
Psychiatric: Cooperative, Appropriate mood & affect.
Review / Management
Results review: Lab results : Laboratory,
All Results: 7/3/2012 9:32 AM CDT Occult Bld Stl Negative .
ECG interpretation: EKG with sinus rhythm, rate 57.
Impression and Plan
Diagnosis
Anxiety Disorder (ICD9 300.00).
Neoplasm of Uncertain Behavior (ICD9 238.9).
Chronic Tension Headaches (ICD9 307.81).
Degenerative disc disease, cervical (ICD9 722.4).
Depressive Disorder (ICD9 311).
Essential Hypertension, Benign (ICD9 401.1).
Hyperlipidemia LDL Goal < 100 (ICD9 272.4).
Need for Shingles Vaccine (ICD9 V05.4).
Prediabetes (ICD9 790.29).
Screening for Malignant Neoplasms of Colon (ICD9 V76.51).
Screening for Malignant Neoplasms of Prostate (ICD9 V76.44).
Screening for Malignant Neoplasms of Testis (ICD9 V76.45).
Well man health examination (ICD9 V70.0).
Plan: BP usually good. I reviewed pt's home BP readings today. BP better when nurse checked it but elevated some when I checked it. Continue current BP meds and continue monitoring BP. Pt takes fioricet about 1-3 times per month. Headache usually comes on if he sleeps in an uncomfortable position, aggravating his neck pain which then leads to tension headache. Pt seldomly takes flexeril. Plan shave biopsy of skin lesion on right cheek within next month. Pt says he cannot have biopsy until next month because his wife is going to have cataract surgery on one eye in 2 days, followed by cataract surgery on other eye about 2 weeks later. Depression and anxiety are well-controlled. Maintain low fat, low chol, low CHO diet to help keep cholesterol controlled and reduce likelihood of developing DM. Hyperlipidemia is under excellent control.
.
Orders
Orders.
In Office Patient Care:
Zostavax ORDER SET (Ordered)
Pharmacy:
zoster vaccine live subcutaneous injection (Ordered): 0.65 mL, subcutaneous, once, # 0.65 mL, 0 Refill(s), Type: Soft Stop, Pharmacy: Majoria Drugs - Terrytown LA
Charges:
90736 zoster shingles vaccine live subcutaneous (Task/Charge) (Ordered): Quantity: 1
Orders.
Pharmacy:
Zoloft 50 mg oral tablet (Ordered): 1 tab(s) ( 50 mg ), PO, Daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: Majoria Drugs - Terrytown LA
Lipitor 20 mg oral tablet (Ordered): 1 tab(s) ( 20 mg ), po, hs, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: Majoria Drugs - Terrytown LA
Exforge 5 mg-160 mg oral tablet (Ordered): 1 tab(s), po, daily, # 90 tab(s), 1 Refill(s), Type: Maintenance, Pharmacy: Majoria Drugs - Terrytown LA
Lipitor 20 mg oral tablet (Discontinued)
Exforge 5 mg-160 mg oral tablet (Discontinued)
Zoloft 50 mg oral tablet (Discontinued)
Orders.
Charges:
82270 blood occult peroxidase actv qual feces 1 deter (Task/Charge) (Ordered): Quantity: 1
93000 ecg routine ecg w/least 12 lds w/i+r (Task/Charge) (Ordered): Quantity: 1
Orders.
Charges (Evaluation and Management):
Return to Clinic (Request) (Ordered): RFV: for biopsy of skin lesion on right cheek or sooner prn, Return in 1 month
Return to Clinic (Request) (Ordered): RFV: for f/u chronic medical problems or sooner prn, Return in 4 months