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HPI Components - Assessment and Plan

maine4me

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I am having trouble with this new patient note. Can someone take a look and tell what if any HPI components they get? I guess my problem is that other her high bp reading at the visit and her discussion about loneliness there is not a real current problem, or chief complaint. I appreciate anyone's thoughts.

Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
309.24 Adjustment disorder with anxious mood

796.2 Elevated Blood Pressure

278.00 Obesity

Additional Plan Details:
Needs mammo, DEXA, PAP, colonoscopy, updated labs
She defers flu shot, Td update, pneumovax and zostavax but I gave her info on all of these today, t/c next OV
RX given for labs:CMP,lipids, TSH, CBC/DIff
GVH mammo and DEXA orders given

EKG done today:WNL

Gave numbers to call for screening colonoscopy

Support offered for social stressors
Pt intolerant of anxiety rx/SSRI int he past, she defers rx at this time
Advised at least seek counselling for her anxiety, chronic , exacerbated by her dtr moving away over a year ago

WIll plan reeval BP here in 2-3 weeks
WIll consider rx if elevated at that time
Referred for colonoscopy: Yes
Weight - BMI High: Patient counseled

HPI
HPI
Nursing Chief Complaint: new patient

Physician: Here for new pt eval
Prior MD was Dr Richard Ruth

Had nosebleed in November, went to Doylestown ER and was told it was due to "Dry air"
THis did not recur
BP was 174/99 per pt , in ER eval
Blames her high BP on missing her dtr who recently moved to Washington State with her military husband

Never had HTN in the past

Lives with her husband, says he is 14y younger than her and is "distant" so she is very lonely without her dtr
Son is 43 y/o and lives locally so he is helpful to talk to
Otherwise no social support
Best friend died of BRCA in 2002

Just started exercising, plans to get to 1 mi walk daily, now at 100 yards/d

Extensive allergy list reviewed

On no medications

Intolerant of several SSRI's in the past

Has deferred most screening and vaccinations in the past
Vitals:
Height 5 ft 5.5 in / 166.37 cm
Weight 266 lbs / 120.655578 kg
BSA 2.43 m2
BMI 43.6 kg/m2
Temperature 98.0 F / 36.67 C - Oral
Blood Pressure 160/96 Sitting, Left Arm

Pulse 66
Blood Pressure 160/86
Personal Medical History
Personal medical history: Hx of: Obesity

Surgical History
Past Surgical History: Hx of: Gynecological Surgery - "vaginal hernia" repair 2003 (?prolapse?, records unavail), Hysterectomy - 1991, Tonsillectomy

Family History
Family history of CV disease: Positive:: FH hypertension - mom, FH other CV disease - dad AAA at 67
Family History of Endocrine Dx: Positive:: FH of diabetes mellitus - mom and dad

Social History
Social history:
Marital Status: Married
Household members: husband
Occupation: homemaker

Tobacco
Smoking History: Never smoker

Alcohol
Alcohol Intake: None

Substance Use
Substance use: Denies use

ROS
Constitutional: Complains of: Fatigue, Weight gain
Ears, nose, mouth, throat: Complains of: Nosebleeds - see HPI
Cardiovascular: Denies: Chest pain, Exertional dyspnea, Palpitations, Syncope, Peripheral edema
Respiratory: Denies: Cough, Shortness of breath
Gastrointestinal: Denies: Abdominal pain, Nausea, Vomiting, Change in bowel habits, Constipation, Diarrhea, Bloody stools
Genitourinary: DENIES: Change in urinary stream
Skin: Denies: Lesions/changes in moles, Rash
Psychiatric: Complains of: Anxiety - sts mainly worry about her dtr, Depression, Denies: Panic attacks, Sleep disturbances
Endocrine: Denies: Polydipsia, Polyphagia, Polyuria
Hematologic/lymphatic: Denies: Anemia

EXAM
Constitutional
General Appearance: NAD

Eyes
Eye: Bilateral: Normal inspection, PERRL, EOMI, Sclera Anicteric

Ears, Nose, Mouth, Throat
External auditory canal: Bilateral: Normal
Tympanic membrane: Bilateral: Normal
Oropharynx:
Mouth: Normal
Throat/Tonsils: Normal

Neck
Neck:
Muscles: Normal
Range of motion: Normal
Carotids:
Bruit: No
Thyroid:
Thyroid - size: Normal
Neck lymph nodes:
Enlarged nodes: Bilateral: None

Respiratory
Respiratory effort: Normal
Auscultation: Bilateral: Normal

Cardiovascular
Rhythm: Regular
Heart sounds: Normal: S1, S2
Peripheral edema:
Leg: Bilateral: None

Gastrointestinal
Abdomen description: Normal
Bowel sounds: ALL: Normal
Abdominal palpation:
Abdomen: Nontender, Soft
Organomegaly/mass:
Organomegaly: None

Lymphatic
Lymphadenopathy: No

Genitourinary
GU exam deferred: Yes

Skin
Skin:
General color: Normal

Neurologic
Neuro Exam: Grossly Intact, Nonfocal

Psychiatric
Mental status: Grossly normal
Affect: Anxious - rapid, nervous speech, good train of thought, tearful at times discussing her dtr
Orientation: Alert and oriented x3
 
Messages
4,466
Location
Milwaukee WI
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"Here for new patient eval"

The physician's statement of "chief complaint" leads me to believe that this is a preventive visit, new patient.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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