Can anyone take a stab at this and let me know what you think?
Thanks,
Jo
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Chief Complaint: new patient
HPI: 77 y.o. female who is here to estab care w/ new pcp
Health Maintenance:
AAA screen: NEVER
DEXA: NEVER
Mammogram: > 10 YRS
Colorectal ca screen: NEVER
FOBT: DOES EVERY YEAR- NEGATIVE
Depression screen: TODAY
Optho exam: A LITTLE OVER 1 YR
Hep B screen: UNK
Hep C screen: UNK
Flu vaccine: 10/18
Pneumococcal vaccine: NEVER
Zoster vaccine: NEVER
TDap: 2014
Review of Systems:
Constitutional: Negative for weight loss and fever/chills.
Eyes: Negative for visual blurring, double vision, eye pain, scotomata/blind spot, visual loss, red eye and itchy eye.
Ears/Nose/Mouth/Throat: Negative for hearing loss, tinnitus, dizziness, epistaxis, frequent upper respiratory tract infections, sinus trouble, sore throat, runny nose, bleeding gums, dental problem, sinus pain and hoarseness.
Respiratory: Negative for cough, productive sputum, hemoptysis, shortness of breath, wheezing and dyspnea on exertion.
Cardiovascular: Negative for palpitations, irregular heart beat, chest pain, nocturnal dyspnea, trouble lying flat, lower extremity edema and claudication.
Gastrointestinal: Negative for dysphagia, dyspepsia, odynophagia, hematemesis, abdominal pain, exccessive gas or bloating, bright red blood per rectum, constipation, diarrhea, jaundice, nausea, vomiting, abdominal cramps and loose or frequent bowel movements.
Musculoskeletal: Negative for painful gait, back pain, bone pain, muscle pain , muscular weakness, fatigue, nocturnal cramping, joint pain, joint swelling and varicose veins.
Skin: Negative for rash, pruritis, pain, abscess and mass.
Neurologic: Negative for headaches, syncope, paralysis, numbness or tingling of hands, numbness or tingling of feet, involuntary movements, tremor, muscular weakness and vertigo.
Psychiatric: Negative for depression, anxiety, sleep disturbance, difficulty with memory, nervousness, marital problems, abusive relationship, excessive alcohol consumption and illegal drug usage.
Endocrine: Negative for hot flashes, heat/cold tolerance , polyuria and polydipsia.
Hematologic/Lymphatic: Negative for anemia, bleeding problems, easy bruising, fever, night sweats, chills and swollen nodes.
Immunologic/Allergies: Negative for itching, hives and allergies.
History:
Past Medical/Surgical:
Past medical history: Patient has a past medical history of Hyperlipidemia and Hypertension.
Past surgical history: Patient has a past surgical history that includes Cholecystotomy.
Family:
Family history: Patient family history includes Breast Cancer in her daughter; Hypertension in her mother; Ovarian Cancer in her sister.
Social:
Social history: reports that she has never smoked. She has never used smokeless tobacco. She reports that she does not drink alcohol or use drugs. Her sexual activity history is not on file.
History
Drug Use No
History
Sexual Activity
Sexual activity: Not on file
Social History
Occupational History
Not on file.
Fish Oil-Omega-3 Fatty Acids 300-1,000 mg capsule
hydroCHLOROthiazide (HYDRODIURIL) 25 mg tablet
lovastatin (MEVACOR) 20 mg tablet
No current facility-administered medications for this visit.
Allergies:
Allergies: She has No Known Allergies.
Physical Exam:
BP 134/73 | Pulse 97 | Temp 97 °F (36.1 °C) (Tympanic) | Resp 14 | Ht 5′ 5" (1.651 m) | Wt 66.2 kg (146 lb) | SpO2 97% | BMI 24.30 kg/m²
Body mass index is 24.30 kg/(m^2).
Constitutional: no acute distress and well developed/well nourished
Eyes: extra-ocular muscle intact (EOMI) bilaterally, lids/conjunctiva normal bilaterally and anicteric bilaterally
Ears/Nose/Mouth/Throat: oropharynx pink and moist, tympanic membranes intact bilaterally and sinuses nontender
Cardiovascular: nondisplaced place of maximal impulse (PMI), normal s1, s2 , regular rhythm, no murmurs, no rubs and no gallops
Respiratory: clear to auscultation bilaterally, normal chest expansion & respiratory effort, no rales, no wheezing and no accessory muscle use
Back: no deformity and no costo-vertebral tenderness (CVAT)
Gastrointestinal: normal bowel sounds, no hepatosplenomegaly, non-tender and no masses
Musculoskeletal: normal gait, no clubbing, cyanosis and full range of motion of joints: all 4 extremities.
Extremity: no peripheral edema and no swelling/erythema/tenderness
Neuro: alert, awake & oriented times three (AA&O x 3), normal light touch sensation and normal strength
Vascular: No venous stasis changes or ulcers
Lymphatic: no cervical nodes, no axillary nodes , no inguinal nodes, no auricular nodes and no epitrochlear nodes
Psych: normal judgment and insight, normal mood/affect and non-anxious
Skin: no rash, warm and dry
Labs/Imaging:
Assessment/plan:
77 y.o. female here for check up and f/u on HTN and HLD
1. HTN-
– ct pres meds
– BP controlled
2. HLD-
– ct pres meds
– obtain recent blood work results
3. Health Care Maintenance
– check routine labs
– Age appropriate cancer screening: refer for mammo and colonoscopy, rec complete skin exam,
– Bone density screening- recommend Vitamin D 1000 units per day, refer for DEXA
– Optho- recommend annual optho exam
– Podiatry- recommend annual pod exam
– Diet- choose foods low in saturated fats and high in fiber. Fresh food is nutritionally better than most prepared foods. Consume multiple servings of fruits and vegetables every day.
– Exercise- walk briskly (powerwalk) 150 minutes per week (30 minutes a day, 5 days a week)
– Wear seatbelts- anytime you are in a moving vehicle, including the backseat.
– Use helmets- for skiing, snowboarding, in-line skating and biking.
– Safe sex- use condoms to reduce your risk of HIV and STIs, screening for STD’s
– Skin- ABCD’s of skin changes, SPF 15 or greater, avoid prolonged exposure to direct sunlight.
– Oral care: Brush and floss your teeth twice a day.
– Vaccines- Flu- UTD, Tdap- UTD
– PNA vax given, tolerated well, no side effects
Visit Diagnoses and Associated Orders
Hypertension, unspecified type – Primary
ICD-10-CM: I10
ICD-9-CM: 401.9
Postmenopausal
ICD-10-CM: Z78.0
ICD-9-CM: V49.81
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]
Visit for screening mammogram
ICD-10-CM: Z12.31
ICD-9-CM: V76.12
Screening for osteoporosis
ICD-10-CM: Z13.820
ICD-9-CM: V82.81
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]
Senile osteoporosis
ICD-10-CM: M81.0
ICD-9-CM: 733.01
DEXA BONE DENSITY, AXIAL SKELETON [77080 CPT(R)]
Need for prophylactic vaccination against Streptococcus pneumoniae (pneumococcus)
ICD-10-CM: Z23
ICD-9-CM: V03.82
PR PNEUMOCOCCAL VACCINE, 23 VALENT, ADULT [90732 CPT(R)]
pneumococcal 23-val vaccine (PNEUMOVAX) 25 mcg/0.5 mL solution [19753]
Hyperlipidemia, unspecified hyperlipidemia type
ICD-10-CM: E78.5
ICD-9-CM: 272.4