What’s Missing From This Note?

See if you can identify the 33 missing elements that would enhance the documentation for this note. If you need a little help, click on the hints provided.

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Date of Exam:  06/22/2010
Patient Name: Jonathan Smith

Medical Record # 06500

CC: “Feeling Badly”  “Fatigue”

This patient is a 72 year-old white male who states that he started “feeling bad” he complains of generalized fatigue. He also states he is having pain which is progressing. 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 replacement. 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. He worked in his garden last week.

Past Medical:
BPH, 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:

Aspirin 81mg
Daily Vitamin

Eyes: Glasses,
ENMT: Sinusitis, slight hearing loss, M&T normal
Respiratory:  c/o nagging cough
GI: GERD, controlled with meds
M/S: Osteoarthritis
Integument: Skin lesions
Neurological: Normal
Psychiatric: Normal, age appropriate
Endocrine: Diabetes

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.”

ENMT:  Normal other than nasal inflammation, dentures
Cardiovascular: Normal
Respiratory: Exhibits shortness of breath
Gastrointestinal: Normal bowel sound x4, No tenderness
Left Knee: Walks with slight limp.
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 extremities are normal on exam.

Administer insulin per sliding scale.
Rapid influenza test: negative
X-Ray: Rx given for X-rays
RX: Vibramycin
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. we discussed the possibility of a systemic infection.

I recommended his daughter pick him up, stay with him tonight and come with him tomorrow. 

Type II DM, Elevated Glucose, 250.02
Hypertension, 401.1
Fatigue, 780.79
Painful knee, status post TKA 719.46, V43.65
SOB, Abnormal chest sounds, Cough, 786.05, 786.7, 786.2

William Banister, M.D.

Hint 1: Identifier
Hint 2: Identifier
Hint 3: HPI
Hint 4: HPI
Hint 5: HPI
Hint 6: HPI
Hint 7: HPI
Hint 8: Social Hx
Hint 9: HPI
Hint 10: PMH
Hint 11: FH
Hint 12: ROS
Hint 13: ROS
Hint 14: ROS
Hint 15: Exam
Hint 16: Exam
Hint 17: Exam
Hint 18: Exam
Hint 19: Exam
Hint 20: MDM
Hint 21: MDM
Hint 22: MDM
Hint 23: MDM
Hint 24: MDM
Hint 25: MDM
Hint 26: MDM
Hint 27: MDM
Hint 28: MDM
Hint 29: MDM
Hint 30: MDM
Hint 31: MDM
Hint 32: MDM
Hint 33: Signature

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