maine4me
Guru
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
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