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CHIEF COMPLAINT / HPI:
(fullName), a (age) year old (sex) patient, presents today with symptoms related to poor nutrition. (He_She) has been experiencing {anemia | dysphagia | enteropathy | decreased work performance | impaired learning ability}.
CURRENT MEDICATIONS: {Vicodin | Oxycontin | Percodan | Percocet | Lortab | Lorcet | Vicodin ES | Darvocet N100 | Skelaxin | Zanaflex | Celebrex | Vioxx | Voltaren | Anti-biotics | Anti-Hypertensive medication | Cholesterol Medication | Pepsid | Neurontin | Elavil | None | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Arthrotec | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec}
ALLERGIES: { | | | | No Known Drug Allergies | Aspirin results in {ALLERGIC REACTION} | Penicillin results in {ALLERGIC REACTION} | Sulfa Drugs result in {ALLERGIC REACTION} | {LIST MEDICATIONS} results in {ALLERGIC REACTION} | | {ALLERGIES MEDICATIONS} | {ALLERGIES FOOD} | {ALLERGIES ENVIRONMENT} | | None | Aspirin | Penicillin | Sulfa drugs | | Bees - wasps | Hay fever | Pineapple | Strawberries}
Negative | Positive, as described in the history above | Positive for the following systems; {MEDICAL SYSTEMS}: {Negative | Positive, as described in the history above | Positive for the following systems; {MEDICAL SYSTEMS}}.
Appendectomy | Cardiac Bypass | Cataract removal | Colonoscopy | Cosmetic surgery | Gall bladder removal | Rhinoplasty | Tonsillectomy | Tracheotomy | Arterial shunt | Cardiac nodal ablation | Pacemaker insertion | PIC line placement | Porta cath placement | Breast reconstruction | Breast enlargement | Heart valve replacement | Indwelling defibrillator | Laparoscopy | Splenectomy | Whipple's procedure | Hernia repair | Liver biopsy | Nephrectomy | Repair of AAA | Stomach stapling | Hysterectomy | Salpingectomy | Vasectomy | Colon resection | C-section | Tubal ligation | Negative | Appendectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cardiac Bypass {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cataract removal {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Colonoscopy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cosmetic surgery {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Gall bladder removal {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Rhinoplasty {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tonsillectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tracheotomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Arterial shunt{ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cardiac nodal ablation {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Pacemaker insertion {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | PIC line placement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Porta cath placement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Breast reconstruction {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Breast enlargement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Heart valve replacement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Indwelling defibrillator {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Laparoscopy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Splenectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Whipple's procedure {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Hernia repair {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Liver biopsy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Nephrectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Repair of AAA {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Stomach stapling {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Hysterectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Salpingectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Vasectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Colon resection {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | C-section {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tubal ligation {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | A-V fistula for dialysis: {Appendectomy | Cardiac Bypass | Cataract removal | Colonoscopy | Cosmetic surgery | Gall bladder removal | Rhinoplasty | Tonsillectomy | Tracheotomy | Arterial shunt | Cardiac nodal ablation | Pacemaker insertion | PIC line placement | Porta cath placement | Breast reconstruction | Breast enlargement | Heart valve replacement | Indwelling defibrillator | Laparoscopy | Splenectomy | Whipple's procedure | Hernia repair | Liver biopsy | Nephrectomy | Repair of AAA | Stomach stapling | Hysterectomy | Salpingectomy | Vasectomy | Colon resection | C-section | Tubal ligation | Negative | Appendectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cardiac Bypass {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cataract removal {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Colonoscopy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cosmetic surgery {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Gall bladder removal {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Rhinoplasty {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tonsillectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tracheotomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Arterial shunt{ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cardiac nodal ablation {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Pacemaker insertion {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | PIC line placement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Porta cath placement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Breast reconstruction {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Breast enlargement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Heart valve replacement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Indwelling defibrillator {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Laparoscopy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Splenectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Whipple's procedure {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Hernia repair {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Liver biopsy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Nephrectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Repair of AAA {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Stomach stapling {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Hysterectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Salpingectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Vasectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Colon resection {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | C-section {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tubal ligation {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | A-V fistula for dialysis}.
OBJECTIVE EVALUATION:
Upon initial observation, (firstName) appeared to be {a well nourished and generally healthy | a well nourished but generally ill | a thin but well nourished and generally healthy | a thin, well nourished but generally ill | a heavy but generally healthy | a heavy and generally ill | an obese but generally healthy | an obese and generally ill} (age) year old {Oriental | | Caucasian | Black | Hispanic | Asian | Indian | American Indian} (SEX), {in no obvious distress | in severe respiratory distress | having some respiratory difficulty | in obvious physical pain | having difficulty getting comfortable | in an agitated state | worried looking} with {normal skin tone | a "shocky" appearance and pale looking skin | a "shocky" appearance and ashen looking skin | a "shocky" appearance and cyanotic looking skin}. (He_She) was {alert and fully oriented to person place and thing | alert and oriented to person and place only | alert and oriented to person only | alert but disoriented to person, place and time | neither alert nor oriented}, {standing comfortably in the exam room | standing uncomfortably in the exam room | pacing the exam room, in great discomfort | seated in a chair, resting comfortably | seated on a chair uneasily | seated on a chair, in great discomfort | seated on the exam bed, resting comfortably | seated on the exam bed, uneasily | seated on the exam bed in great discomfort | lying semi-reclined on the exam bed, resting comfortably | lying semi-reclined on the exam bed, uneasily | lying semi-reclined on the exam bed in great discomfort | lying supine on the exam bed, resting comfortably | lying supine on the exam bed, restlessly | lying supine on the exam bed in great discomfort | sleeping quietly on the exam bed | lying unconscious on the exam bed}.
PHYSICAL EXAMINATION:
Vital Signs - Blood pressure {90 | 95 | 100 | 105 | 110 | 115 | 120 | 125 | 130 | 135 | 140 | 145 | 150 | 155 | 160 | 165 | 170 | 175 | 180 | 185 | 190}/{60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100 | 105 | 110}.
Heart rate – {<30 | 30 | 32 | 34 | 36 | 38 | 40 | 42 | 44 | 46 | 48 | 50 | 52 | 54 | 56 | 58 | 60 | 62 | 64 | 66 | 68 | 70 | 72 | 74 | 76 | 78 | 80 | 82 | 84 | 86 | 88 | 90 | 92 | 94 | 96 | 98 | 100 | 102 | 104 | 106 | 108 | 110 | 112 | 114 | 116 | 118 | 120 | 122 | 124 | 126 | 128 | 130 | 132 | 134 | 136 | 138 | 140 | 144 | 148 | 152 | 156 | 160 | 164 | 168 | 172 | 176 | 180 | 184 | 188 | 192 | 196 | 200 | 210 | 220 | 230 | 240 | 250 | 260 | 270 | 280 | 290 | 300 | >300} bpm.
Respiratory rate - {26 | <10 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 18 | 20 | 22 | 24 | 25 | 30 | >30} per minute,
Temperature - {NA | {TEMPERATURE} per os | {TEMPERATURE} per axilla | {TEMPERATURE} per rectum | {TEMPERATURE} per auditory canal}.
{HEENT: Head, normocephalic atraumatic; eyes, pupils are equal, round and reactive to light and accommodation, extraocular muscles are intact, sclera is non-icteric with no erythema; ears, canals and tympanic membranes appear clear with no exudate, excess | | {PE-HEENT-WITH FINDINGS}}
{NECK: Supple, non-tender, no masses, no adenopathy, trachea is midline and euthyroid. No jugular venous distension is present and no carotid bruits were auscultated. | | {PE-NECK-WITH FINDINGS}}
{LUNGS: The patient has normal configuration and symmetrical movement during respirations. There is no evidence of intercostal retractions. On palpation, there is no tenderness, tactile fremitus, chest wall expansion, or diaphragmatic excursion. Breath sou | | {PE-LUNGS-WITH FINDINGS}}
{HEART: Regular rate and rhythm, S1, S2, with physiological splitting of S2 on inspiration and no audible murmur or additional heart sounds. The apical impulse is in the mid-clavicular line. No lifts, heaves, rubs or gallops. No murmur is detected. | | {PE-HEART-WITH FINDINGS}}
{ABDOMEN: Soft, non-tender, non-distended. Bowel sounds are present in all four quadrants. No palpable masses or evidence of hepatomegaly or splenomegaly. | | {PE-ABDOMEN-WITH FINDINGS}}
{NEUROLOGIC: The patient is alert and oriented X 3. Cranial nerves II through XII are intact, reflexes are 2+ and symmetrical bilaterally at biceps, triceps, supinator, and patella. Bilateral plantarflexion with no clonus appreciated. | | {NEUROLOGIC: The patient is alert and oriented X 3. Cranial nerves II through XII are intact, reflexes are 2+ and symmetrical bilaterally at biceps, triceps, supinator, and patella. Bilateral plantarflexion with no clonus appreciated. | | {PE-NEURO-WITH FINDINGS}-WITH FINDINGS}}
{EXTREMITIES: Normal appearance with full range of motion in all four extremities with good muscle tone and symmetry. No evidence of cyanosis, edema, digital clubbing, or other abnormalities. Movement is fluid and coordinated. | | {PE-EXTREMITIES-WITH FINDINGS}}
{INTEGUMENT; no sign of rashes, eruptions, scars, café au lait spots, tattoos, moles, or unusual hair pattern. | | {PE-INTEGUMENT-WITH FINDINGS}}
{NEUROLOGIC: The patient is alert and oriented X 3. Cranial nerves II through XII are intact, reflexes are 2+ and symmetrical bilaterally at biceps, triceps, supinator, and patella. Bilateral plantarflexion with no clonus appreciated. | | {NEUROLOGIC: The patient is alert and oriented X 3. Cranial nerves II through XII are intact, reflexes are 2+ and symmetrical bilaterally at biceps, triceps, supinator, and patella. Bilateral plantarflexion with no clonus appreciated. | | {PE-NEURO-WITH FINDINGS}-WITH FINDINGS}}
LABS / STUDIES:
The following diagnostic studies were performed;
Laboratory tests - {}
INITIAL TREATMENT: The patient has symptoms consistent with dietary anemia | dysphagia | enteropathy | decreased work performance | impaired learning ability. A daily supplement of oral Iron is recommended. Symptoms are expected to improve in two to three weeks.
DISPOSITION: Patient diagnosis; Dietary anemia | dysphagia | enteropathy | decreased work performance | impaired learning ability
(fullName) was examined and treated as stated above for today's complaints. Follow up at this office is scheduled for four weeks from today or sooner if additional symptoms occur or existing symptoms worsen.
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