maine4me
Guru
I am looking for another set of eyes. Do think this note in anyway would support a preventive visit? I feel like it does not, although comprehensive the doctor has clearly indicated diagnoses in the assessment, and although there is no treatment change is ordering labs.
Assessment and Plan
Ambulatory Assessment/Plan:
IBS (irritable bowel syndrome) - 564.1
Stable with diet, fish oil, probiotics
Continue. Call if worse.
Iron deficiency - 280.9
Continue with supplement
Will recheck labs
New Diagnostics
Total Iron Level-Q, 09/24/14 @ ABC Lab
Ferritin-Q, 09/24/14 @ ABC Lab
Iron TIBC-Q, 09/24/14 @ ABC Lab
Additional Plan Detail:
FU for PE
Labs ordered ABC as listed. We will call w/ results
Explained mammo is recommended annually. She defers for now
Declines flu vaccine.
New Diagnostics
CBC w diff/plts-Q, 09/24/14 @ ABC Lab
BMP-Q, 09/24/14 @ ABC Lab
Lipid Panel-Q, 09/24/14 @ ABC Lab
TSH 3 Gen/Free T4-Q, 09/24/14 @ ABC Lab
New Reported Medications
Lactobacillus Acidophilus (Probiotic Acidophilus) 1 CAP CAPSULE: 1 CAP PO DAILY CAP
Multivitamin (Multivitamin Capsule) 1 CAP CAP: 1 CAP PO DAILY #30 CAP
OMEGA-3/DHA/EPA/FISH OIL (FISH OIL 1,000 MG SOFTGEL) 1 EACH CAPSULE: 2 EACH PO DAILY CAP
Calcium Carbonate/Vitamin D3 (Calcium 500 + D3 Tablet) 1 EACH TABLET: 1 EACH PO DAILY TAB
Iron Polysaccharides Complex (Fe-Tinic 150) 150 MG CAPSULE: 150 MG PO DAILY CAP
Education resources provided: No
Patient Education:
Patient care time (minutes): 30
HPI
HPI
Chief Complaint: get reestablished-PE
Physician: Here today as a new pt. She was previously a pt of this office, and was last seen 2011. She has no particular concerns.
She's getting period every 3 weeks.
Has IBS- avoids gluten and dairy - no sxs
Goes to derm- for hair loss. Labs were done - all nl- likely hereditary. Iron was low, but normal H&H
gyn - In town- Dr. W.
Last labs- 1.5 yrs ago
mammo- 2 yrs ago. Had cyst that resolved in breast. Doesn't want to repeat this year
Provided Portal Information: Yes
Pertinent PMH,PSH,FHX,SOC HX: Reviewed
Vitals:
Height 62.25 in / 158.12 cm
Weight 94 lbs / 42.638 kg
BSA 1.36 m2
BMI 17.1 kg/m2
Blood Pressure 102/66 Sitting, Left Arm
Personal Medical History
Personal medical history: Hx of: Other - IBS
Para: 2
Surgical History
Past Surgical History: Hx of: Cesarean Section
Family History
Family History:
FH: Alzheimers disease
05 GRANDFATHER
FH: HTN (hypertension)
19 MOTHER
Social History
Social history:
Marital Status: Married
Details re: marital status: 2 sons
Household members: husband
Occupation: dental practice
Diet and Exercise
Dietary habits:
Current Diet: Well balanced
Exercise/physical activity:
Physical activity: Walking
Frequency: 3-4 times per week
Duration: 45-60 minutes/day
Tobacco
Smoking Status: Never smoker
ROS
Constitutional: Denies: Fever
Ears, nose, mouth, throat: Denies: Ear pain, Facial pain, Nasal discharge, Hoarseness, Sore throat
Cardiovascular: Denies: Chest pain, Decr. exercise tolerance, Palpitations, Peripheral edema
Respiratory: Denies: Cough, Sputum production, Hemoptysis, Shortness of breath, Pleuritic pain
Gastrointestinal: Denies: Abdominal pain, Nausea, Vomiting, Change in bowel habits, Black stools, Bloody stools
Genitourinary:
Genitourinary: Denies: Dysuria, Hematuria, Urinary frequency, Urinary urgency
Musculoskeletal: Denies: Back pain, Joint pain
Skin: Denies: Lesions/changes in moles, Rash
Neurological: Complains of: Headache - monthly and food related - choc or doesn't have tea, Denies: Migraine
Psychiatric: Denies: Anxiety, Depression
Hematologic/lymphatic: Denies: Anemia
Allergic/immunologic: Denies: Seasonal allergies
EXAM
Constitutional
General Appearance: NAD
Eyes
Eye: Bilateral: Normal inspection
Conjunctiva: Bilateral: Normal
Ears, Nose, Mouth, Throat
External auditory canal: Bilateral: Normal
Tympanic membrane: Bilateral: Normal
Nostril: Bilateral: Normal
Sinus tenderness: Bilateral: No tenderness
Oropharynx:
Mouth: Normal
Throat/Tonsils: Normal
Neck
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
Abnormal heart sounds: No: Murmur, Rub
Peripheral pulses:
Posterior tibial: Bilateral: Normal
Peripheral edema:
Leg: Bilateral: None
Gastrointestinal
Abdomen description: Normal
Bowel sounds: ALL: Hyperactive
Abdominal palpation:
Abdomen: Nontender
Organomegaly/mass:
Organomegaly: None
Mass: None
Musculoskeletal
Gait: Normal
Skin
Skin:
General color: pwd
Neurologic
Neuro Exam: Grossly Intact, Nonfocal
Deep tendon reflexes:
Knee: Bilateral: Normal
Motor: Grossly intact
Speech: Normal
Psychiatric
Affect: Normal
Assessment and Plan
Ambulatory Assessment/Plan:
IBS (irritable bowel syndrome) - 564.1
Stable with diet, fish oil, probiotics
Continue. Call if worse.
Iron deficiency - 280.9
Continue with supplement
Will recheck labs
New Diagnostics
Total Iron Level-Q, 09/24/14 @ ABC Lab
Ferritin-Q, 09/24/14 @ ABC Lab
Iron TIBC-Q, 09/24/14 @ ABC Lab
Additional Plan Detail:
FU for PE
Labs ordered ABC as listed. We will call w/ results
Explained mammo is recommended annually. She defers for now
Declines flu vaccine.
New Diagnostics
CBC w diff/plts-Q, 09/24/14 @ ABC Lab
BMP-Q, 09/24/14 @ ABC Lab
Lipid Panel-Q, 09/24/14 @ ABC Lab
TSH 3 Gen/Free T4-Q, 09/24/14 @ ABC Lab
New Reported Medications
Lactobacillus Acidophilus (Probiotic Acidophilus) 1 CAP CAPSULE: 1 CAP PO DAILY CAP
Multivitamin (Multivitamin Capsule) 1 CAP CAP: 1 CAP PO DAILY #30 CAP
OMEGA-3/DHA/EPA/FISH OIL (FISH OIL 1,000 MG SOFTGEL) 1 EACH CAPSULE: 2 EACH PO DAILY CAP
Calcium Carbonate/Vitamin D3 (Calcium 500 + D3 Tablet) 1 EACH TABLET: 1 EACH PO DAILY TAB
Iron Polysaccharides Complex (Fe-Tinic 150) 150 MG CAPSULE: 150 MG PO DAILY CAP
Education resources provided: No
Patient Education:
Patient care time (minutes): 30
HPI
HPI
Chief Complaint: get reestablished-PE
Physician: Here today as a new pt. She was previously a pt of this office, and was last seen 2011. She has no particular concerns.
She's getting period every 3 weeks.
Has IBS- avoids gluten and dairy - no sxs
Goes to derm- for hair loss. Labs were done - all nl- likely hereditary. Iron was low, but normal H&H
gyn - In town- Dr. W.
Last labs- 1.5 yrs ago
mammo- 2 yrs ago. Had cyst that resolved in breast. Doesn't want to repeat this year
Provided Portal Information: Yes
Pertinent PMH,PSH,FHX,SOC HX: Reviewed
Vitals:
Height 62.25 in / 158.12 cm
Weight 94 lbs / 42.638 kg
BSA 1.36 m2
BMI 17.1 kg/m2
Blood Pressure 102/66 Sitting, Left Arm
Personal Medical History
Personal medical history: Hx of: Other - IBS
Para: 2
Surgical History
Past Surgical History: Hx of: Cesarean Section
Family History
Family History:
FH: Alzheimers disease
05 GRANDFATHER
FH: HTN (hypertension)
19 MOTHER
Social History
Social history:
Marital Status: Married
Details re: marital status: 2 sons
Household members: husband
Occupation: dental practice
Diet and Exercise
Dietary habits:
Current Diet: Well balanced
Exercise/physical activity:
Physical activity: Walking
Frequency: 3-4 times per week
Duration: 45-60 minutes/day
Tobacco
Smoking Status: Never smoker
ROS
Constitutional: Denies: Fever
Ears, nose, mouth, throat: Denies: Ear pain, Facial pain, Nasal discharge, Hoarseness, Sore throat
Cardiovascular: Denies: Chest pain, Decr. exercise tolerance, Palpitations, Peripheral edema
Respiratory: Denies: Cough, Sputum production, Hemoptysis, Shortness of breath, Pleuritic pain
Gastrointestinal: Denies: Abdominal pain, Nausea, Vomiting, Change in bowel habits, Black stools, Bloody stools
Genitourinary:
Genitourinary: Denies: Dysuria, Hematuria, Urinary frequency, Urinary urgency
Musculoskeletal: Denies: Back pain, Joint pain
Skin: Denies: Lesions/changes in moles, Rash
Neurological: Complains of: Headache - monthly and food related - choc or doesn't have tea, Denies: Migraine
Psychiatric: Denies: Anxiety, Depression
Hematologic/lymphatic: Denies: Anemia
Allergic/immunologic: Denies: Seasonal allergies
EXAM
Constitutional
General Appearance: NAD
Eyes
Eye: Bilateral: Normal inspection
Conjunctiva: Bilateral: Normal
Ears, Nose, Mouth, Throat
External auditory canal: Bilateral: Normal
Tympanic membrane: Bilateral: Normal
Nostril: Bilateral: Normal
Sinus tenderness: Bilateral: No tenderness
Oropharynx:
Mouth: Normal
Throat/Tonsils: Normal
Neck
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
Abnormal heart sounds: No: Murmur, Rub
Peripheral pulses:
Posterior tibial: Bilateral: Normal
Peripheral edema:
Leg: Bilateral: None
Gastrointestinal
Abdomen description: Normal
Bowel sounds: ALL: Hyperactive
Abdominal palpation:
Abdomen: Nontender
Organomegaly/mass:
Organomegaly: None
Mass: None
Musculoskeletal
Gait: Normal
Skin
Skin:
General color: pwd
Neurologic
Neuro Exam: Grossly Intact, Nonfocal
Deep tendon reflexes:
Knee: Bilateral: Normal
Motor: Grossly intact
Speech: Normal
Psychiatric
Affect: Normal