Professional Documents
Culture Documents
HPI:
Associated: Lost job and insurance last month (June 2016), wishes to become established as
new patient at free clinic and requests assistance with purchasing medications. Last pap test:
has been a while, last mammogram: 2013, and last colonoscopy and endoscopy: 2012.
Medical Hx: Migraine, hypertension, palpitations, chest pains, asthma, bulging lumbar disc,
right shoulder torn biceps, tendonitis, bursitis, right frozen shoulder, right knee torn meniscus
and anterior cruciate ligament, gout, chronic right ankle sprain, bilateral carpal tunnel syndrome,
increased prolactin level, whip lash (x3), pseudo seizures, restless leg syndrome, diverticulosis,
irritable bowel syndrome, acid reflux, overactive bladder, neuropathy, TIA (x2, last 2013),
myocardial infarction (2015), and uterine fibroid. Several hospitalizations with previous
surgeries, TIA, and MI, last hospitalization February 2016 due to uterine fibroid.
Surgical Hx: Diagnostic laparoscopy, Left Achilles tendon repair, dilation and curettage,
bilateral tubal ligation, endoscopy, colonoscopy
Social Hx: Lives with husband Michael of 20 years who has diagnosis of cystic fibrosis, has
three daughters and seven grandchildren all living outside of the home. Not currently employed,
states disabled since back surgery in 2001. Denies past or present tobacco, alcohol, or drug
use.
Family Hx: Mother (deceased, age 70s- heart attack) heart disease, hypertension; dad
(deceased, age 70s- heart attack) heart disease, hypertension; no siblings.
Skin: Denies rash, hives, puritis, edema, ulcerations, moles, alopecia, excessive ecchymosis, or
erythema.
MS: Reports generalized joint pain at times, states is worse when walking or with activity.
Denies swelling, decreased range of motion, muscle pain, or muscle spasms.
Neuro: Reports psudo seizures and starring into space, unable to remember the last episode,
states has been a while. Reports weakness in right arm and leg since last TIA in 2013. Denies
headaches, neuropathy, sudden loss of vision or speech, vertigo, or tremors.
Psych: Reports depression and anxiety at times, states she cleans house when she feels anxious
and that seems to help with the symptoms. Denies feelings of agitation, panic, suicidal thoughts
or tendencies, or hallucinations.
(O)
Vital signs: T: (not available) P: 70 R: 18 BP: 146/84 HT: 57 WT: 297 pounds BMI:
46.5 Pain: 4/10
Constitutional - Pleasant, well-groomed Caucasian woman, dressed appropriately for age and
weather. Cooperative and answers questions appropriately. No grimacing, guarding, or acute
distress noted.
HEENT: Normocephallic. No infestations, flakes, abrasions, raised areas noted to scalp,
eyebrows, eyelashes, or facial area. Pupils equal, round, reactive to light and accommodation,
2mm and brisk. Sclera white in color with no redness or irritations noted, conjunctiva pink. Red
reflex visualized in bilateral eyes. No nystagmus noted. Denies tenderness of pinna or tragus
bilaterally, tympanic membrane visualized, pearly gray bilaterally, no drainage, bulging, or
redness noted to membrane, or outer canal, no cerumen noted. Nasal passageways clear, no
redness, sores, deviated septum, polyps, or nasal drainage noted. Lips pink and moist, no
ulcerations or crustations noted. Oral cavity pink and moist, no ulcerations, dental caries, or
abnormalities noted, tongue midline, able to move freely without difficulty, no glossitis, palate
rises equally, uvula midline, tonsils visualized 2+ bilaterally, Trachea midline, thyroid palpated,
no goiter noted or tenderness reported. Facial, neck, and supracervical lymph nodes non-
palpable and non-tender.
Skin: Warm, dry, and intact, no lacerations, abrasions, ulcerations, ecchymosis, erythema, or
rashes.
Respiratory: Lungs clear all lobes bilaterally, no wheezing, crackles, or rhonchi noted. No
cough noted. Lung expansion equal and symmetrical bilaterally. AP diameter of chest 1:2, no
barrel chest noted. No clubbing of nailbeds.
Cardio: Regular rate rhythm, S1, S2 present, no rubs, gallops, murmurs noted. One+ pitting
edema noted to bilateral lower extremities. No jugular vein distension, spider veins, or
varicosities noted.
GI: Normoactive bowel sounds noted in all four quadrants. Abdomen non-distended, soft, non-
tender, no organomegally noted.
GU: No bladder distension noted. Denies CVA tenderness bilaterally.
Psych: Appropriately interacts and answers questions, appropriate affect, no flat affect noted.
Does not appear anxious or in depressed mood, no fidgeting noted.
Other: Papanicolou (Pap) test and breast exam completed with chaperone present. No lesions
present to labia, vaginal wall or cervix, no nabothain cyst noted to cervix, no fishy odor or
discharge. Breast symmetrical with no dimpling, or nipple drainage noted. Multiple mobile, two
cm diameter or less, fibrocystic nodules noted to outer aspects of bilateral breast, reports slightly
tender upon palpation. No nodules noted or tenderness reported in axilla areas bilaterally.
Bimanual exam done, unable to palpate ovaries bilaterally.
(A)
Dx: (include ICD 10 code - http://www.icd10data.com/ICD10CM/Codes )(list as many
diagnoses as indicated)
Z00.0 Encounter for general adult medical exam; Z01.41 Encounter for routine gynecological
exam
Differentials:
Pt.Education:_Use nitroglycerin as prescribed at the onset of chest pain or angina. Call 911 if
chest pain unrelieved after second dose of nitroglycerin. Always notify health care provider of
angina attacks that require the use of nitroglycerin. Informed patient that females do not often
have classic symptoms when experiencing a heart attack, symptoms often present as neck, jaw,
shoulder, back, or arm pain, or can also mimic heartburn or acid reflux. Instructed to notify
practitioner of new symptoms or worsening seizure activity. Fibrocystic changes in breast are
normal, especially in women ages 30-50, and are not a precursor to breast cancer. Symptoms are
often worse and noticed around the time of menstrual period. Previous research has suggested
that reducing amounts of caffeine (such as the green tea) could help to decrease symptoms. The
mammogram should show if there are any concerning changes to the breast tissue or area of
concern that need further investigation.
Preventive care: Reduce caffeine intake, may take Vitamin E 1000mg or 1500IU once daily in
hopes to reduce symptoms of fibrocystic changes of the breast. Follow a cardiac diet, decreasing
the amounts of fried and increased sodium foods. Encouraged to elevate legs as much as
possible and elevate on pillow at night to help reduce edema.
Follow-up instructions: Will notify of Pap test results when available, approximately one
week. Mammogram, Neurology, Endocrinology, and Cardiology consult at the upcoming local
R.A.M. Follow up at the Health Wagon clinic one week after R.A.M. (approximately one month
from now).
Other: None
Discuss how you addressed at least 3 NONPF competencies during this visit. (See
NONPF competency list available at
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecom
petenciesfinal2012.pdf )
Cost Helper [Internet]. (2016a). Blood test cost: How much do blood tests cost? Retrieved
Cost Helper [Internet]. (2016b). EKG cost: How much does an EKG cost? Retrieved from
Cost Helper [Internet]. (2016c). Mammogram cost: How much does a mammogram cost?
Thomas, A. C., Crabtree, M. K., Delaney, K., Dumas, M. A., Kleinpell, R., Marfell, J. Wolf,
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcor
ecompetenciesfinal2012.pdf