What’s Missing From This Note?

Date of Exam:  06/22/2010
Patient Name: Jonathan P. Smith
Date of Birth: 3/24/1940
Medical Record # 06500

CC: "Feeling Badly"  "Fatigue"

HPI:
This patient is a 72 year-old white male who states that 4 days ago he started "feeling bad" he complains of generalized fatigueand flu like symptoms. He also states he is having pain in his left knee which is progressing. He does not recall an injury that would cause the pain. He is also complaining of a shortness of breath and slight cough and has had night sweats, which he relates to seasonal allergies. He has stayed in for the past 3 days taking Nyquil and over-the-counter Claritin. He states he is getting worse and comes in for a checkup. He has a history of a total joint replacementin the left knee five years ago. He did well with no post-op complications and was pleased with the outcome and the function it offered. He even missed his weekly lunch date with his friend at River Crossing Assisted Living Center yesterday. John is retired from the postal service, and is widowed, and in generally good health for his age. He worked in his garden last weekbending and squatting.

Past Medical:
BPH, Type II Diabetes, GERD, Mild Hypertension,history of MRSA

Past Surgical:
Appendectomy when he was a teenager, TURP 12 years ago, TKA 5 year ago.

Family History:
Non-ContributoryNon-Contributory
Reviewed with the patient and no indication the presenting problems have a hereditary link.

Medications:
Glucophage
Zantac
Claritin
Lisinopril
Aspirin 81mg
Daily Vitamin

ROS:
Eyes: Glasses, last eye exam 2007
ENMT: Sinusitis, slight hearing lossin left ear, M&T normal
Cardiovascular: Hypertension
Respiratory:  c/o nagging cough
GI: GERD, controlled with meds
GU: BPH, TURP 
M/S: Osteoarthritis
Integument: Skin lesions
Neurological: Normal
Psychiatric: Normal, age appropriate
Endocrine: Diabetes

EXAM:
Constitutional: Hgt. 5’9", Wt. 230 Lbs, BMI 34 Temp. 101.2, Resp. 24, BP. 142/92, Pulse 82

WD obese pleasant male well known to me, he is concerned today because he says he feels badly and states he "is just not his normal self."

Eyes: PERRLA
ENMT:  Normal other than nasal inflammation, dentures
Cardiovascular: NormalNormal Positive for murmur
Respiratory: Exhibits shortness of breath, coughs with deep inspiration, crackles and rales to bilateral lower lobes.
Gastrointestinal: Normal bowel sound x4, No tenderness, slight enlargement of spleen
Musculoskeletal:
Left Knee: Walks with slight limp. Pain with palpation and ROM, No joint instability, there is swelling and erythema noted, and is warm to touch.
Right Knee: Normal
Skin: No rashes or abrasions. Well healed incision from previous surgery
Neurological: Sensation is normal. DTRs are normal.
Cardiovascular: Popliteal is diminished, pedal pulse is normal.
Lymphatic:  Mild lymphedma to groin, no tenderness is noted. 
Other: No long bone deformities are noted.
Inspection and ROM of the bilateral upper and lower extremities are normal on exam.

PLAN:
Administer 5 units regular insulin per sliding scale.
Rapid influenza test performed in the office: negative
X-Ray: Rx given for X-rays of AP and Lateral Chest with a stat reading. Left knee for routine 4 views
LABS: Glucose, CBC, CMP, UA with C&S, and sputum culture.
RX: Vibramycin 200mg daily, for five days. (First dose today)
RX: For tonight only increase Glucophage to two tablets. (1000 Mg.)

He does have a prosthetic joint. There is slight enlargement of the spleen. No history of a heart murmur. His PMH, indicated he had skin lesions about 18 months ago. After questioning further, I find he had MRSA with multiple skin lesions, however was treated timely and aggressively and there were no indications of further complications. Due to his history and new symptoms, I am concerned about the possibility of a progressing infection; we discussed the possibility of a systemic infection. He is to follow-up with me tomorrow.

I recommended his daughter pick him up, stay with him tonight and come with him tomorrow.   I discussed all of this over the phone with his daughter and she is in agreement. She will pick him up today. He is to call me immediately if his fever elevates to 100.5 or greater, or his cough or SOB worsens during the night.  He is to discontinue Nyquil.  Continue home meds. Once we are over this episode, schedule an eye exam.

IMPRESSION:
Type II DM, Elevated Glucose, 250.02250.02 250.00
Hypertension, 401.1401.1 401.9
Fatigue, 780.79
Painful knee, status post TKA 719.46, V43.65
SOB, Abnormal chest sounds, Cough, 786.05, 786.7, 786.2
Personal Hx. MRSA, V12.04
R/O Systemic infection

William Banister, M.D.