Module 3 medical terminology
Chief complaint
insomnia
PATIENT Eric R Rodriguez DOB 03/01/1965 AGE 52 yrs SEX Male PRN EP108956
FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note SEEN BY Nazir Ashaad DATE 01/05/2017 AGE AT DOS
51 yrs
Not signed
Patient identifying details and demographics
FIRST NAME Eric MIDDLE NAME R LAST NAME Rodriguez SSN -
SEX Male DATE OF BIRTH 03/01/1965 DATE OF DEATH - PRN EP108956
ETHNICITY Hispanic or Latino
PREF. LANGUAGE
English
RACE Patient declined to specify
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 783 Washington Ave
ADDRESS LINE 2 - CITY Hollytown STATE NH ZIP CODE 33220
CONTACT BY Home Phone EMAIL ericr@testpatient
.com HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE - OFFICE EXTENSION
-
FAMILY INFORMATION
NEXT OF KIN Margie Norotz RELATION TO PATIENT Sibling PHONE 5555555555 ADDRESS -
PATIENT'S MOTHER'S MAIDEN NAME
-
Encounter - Date of service: 01/05/17 Patient: Eric R Rodrigue... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...
1 of 4 4/6/17, 3:19 PM
Active Medications
MEDICATION SIG START/STOP ASSOCIATED DX
Eszopiclone 2 MG Oral Tablet 02/14/17 - Insomnia
LamoTRIgine 25 MG Oral Tablet 04/06/17 - -
Lisinopril 10 MG Oral Tablet 07/02/14 - Hypertension
Provider comment: Patient reported daily use. Prescribed by prior clinic. by Nazir Ashaad on 04/05/17
Historical Medications
MEDICATION SIG START/STOP ASSOCIATED DX
LamoTRIgine 25 MG Oral Tablet 03/27/17 - 04/06/17
Bipolar disorder, unspecified
LamoTRIgine 25 MG Oral Tablet - 04/06/17 -
Zaleplon 5 MG Oral Capsule 01/03/17 - 02/14/17
Insomnia
Smoking History
STATUS EFFECTIVE DATE
Never smoker 04/05/2017
Encounter - Date of service: 01/05/17 Patient: Eric R Rodrigue... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...
2 of 4 4/6/17, 3:19 PM
No Family health history recorded
Past medical history
MAJOR EVENTS
MVA 10/31/1978 - Fx femur, full recovery Patient reports multiple concussions from history as collegiate football career. Did not pursue Tx. Meningitis as a young child- full recovery
ONGOING MEDICAL PROBLEMS
Hypertension - Dx in 2014, Tx with antihypertensive medications Weight management
FAMILY HEALTH HISTORY
Father- Hypertension, hypercholesterolemia, died from complications of stroke Mother- Diabetes Type II, hyperthyroidism Paternal Grandfather- Hypertension, congestive heart failure Maternal Grandfather- Dementia, possible Alzheimers disease Paternal Grandmother- Heart problems (unspecified) Maternal Grandmother- Died of breast cancer
SOCIAL HISTORY
Education: Some college Occupation: Financial manager Disability: None Substance Use/Abuse: Drinks alcohol (usually beer) 3-5 drinks/week. Does not smoke. No history of smoking. Marital status: Divorced
NUTRITION HISTORY
Patient was advised to decrease carbohydrate intake in 2014 when a wellness check showed prediabetic levels of blood glucose. He has monitored BG annually since that visit and BG has been WNL since that time.
Patient is advised to decrease saturated fat intake, increase water intake, and increase green, leafy vegetable intake. Dietary changes will continue to be assessed. Dietician consult may be needed.
Family health history
DIAGNOSIS ONSET DATE
Subjective
HPI
Eric is a 38 year old man with a history of hypertension here because he has had difficulty sleeping two weeks ago lasting for 1 week. He states that he thinks he was fine but his wife made him come because he was keeping her up all night. He said he was staying awake all night because he felt "unstoppable." He was writing papers during the night although he notes that he never seemed to finish one because half way through a new topic interested him. He reports that his wife complains that he was extremely or almost too talkative during dinner, and he says he got in trouble at work for making a sexual advance on a co-worker, which is very unlike him. He works in human resources at an investment bank. He denies any weight loss, fevers, chills, or night sweats. He denies any drug use. He also denies any thoughts of harming himself or others. Of note, he says his mom takes "some sort of metal" for her mood swings. He says today he
Encounter - Date of service: 01/05/17 Patient: Eric R Rodrigue... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...
3 of 4 4/6/17, 3:19 PM
feels "a little down" but denies any suicidal or homicidal ideation. He denies any LOC or syncope.
Review of Systems Constitutional: per HPI Neurological: Patient reports paresthesia in bilateral upper limbs. Respiratory: No chest pain, cough, or shortness of breath. Cardiovascular: No chest pain Gastrointestinal: No abdominal pain, distension, or change in bowel movements. Genitourinary: no painful, increased, or decreased urination Musculoskeletal: negative Endocrine: negative
Objective
PE: General: Sitting down, not making eye contact Cardiovascular: RRR, no MRG, 2+ radial and DP pulses bilaterally Abdominal: soft, non-tender Respiratory: lungs clear Neurologic: CN2-12 intact, normal gait, reflexes normal and symmetric HEENT: Atraumatic normocephalic. PERRL. No bleeding from nasal septum. No lymphadenopathy. Psych: flat affect, no SI&HI
Assessment
Otherwise healthy man with symptoms concerning of bipolar disorder but currently not manic or suicidal
Diagnoses attached to this encounter:
(I10) Hypertension
(F31.9) Bipolar disorder, unspecified
(G47.00) Insomnia
Plan
Referral to psychiatrist for evaluation of possible mood disorder.
Continue hypertension medication b.i.d.
Free cloud based EHR
Encounter - Date of service: 01/05/17 Patient: Eric R Rodrigue... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...
4 of 4 4/6/17, 3:19 PM