Soap Note x 3 (24 Hours)

DOB 12/30/1948

AGE 71 yrs

SEX Male

PRN SR0031

Chief complaint

Annual Wellness exam (Appt time: 12:30 PM) (Arrival time: 12:06 PM)

( Patient identifying details and demographics )

FIRST NAME FERNANDO

MIDDLE NAME -

LAST NAME GERDTS

SSN -

SEX Male

DATE OF BIRTH 12/30/1948

DATE OF DEATH -

PRN SR0031

RACE -

ETHNICITY -

PREF. LANGUAGE -

STATUS Active patient

( CONTACT INFORMATION )

NEXT OF KIN -

RELATION TO PATIENT -

PHONE -

ADDRESS -

PATIENT'S MOTHER'S MAIDEN -

NAME

( PATIENT NOTES )

*Cardio/ Dr. Jaime J. Sanchez 2140 W. 68 St. #403 Hialeah 33016 P.3-821-6167 F.3-824-9012 *Reuma/ Dr. Jose Aldrich 351 NW 42 ave. #404 Mia. P.3-856-5733 F.3-441-0396 *Reum/ Dr. Rawan Jumean 8500 SW 92 St. #208 Miami P.3-661-0169 F. 1-888-811-4447

*Gastro/ Dr. Daniel Gelrud 7500 SW 87 Ave. #200 Miami P3-913-0666 F.3-596-4242 for referrals *Oftalmologo/Dr. Gabay 8940 N. Kendall Dr. #400E P.3-598-2020 F.3-270-6430 Liza *Dentist Dr. Sague 305-200-3404

Comment: As noted in lab results.03/2020. by Mario Gonzalez-Leyva on 03/29/20

(E87.8) Other disorders of electrolyte and fluid balance, not elsewhere classified

Chronic 03/29/2020

Comment: As noted in lab results.03/2020. by Mario Gonzalez-Leyva on 03/29/20

Comment: Mild anemia noted in lab results, 09/09/2019 by Mario Gonzalez-Leyva on 09/27/19

(M81.0) Age-related osteoporosis without current pathological fracture

Chronic 09/10/2019

(H20.13) Chronic iridocyclitis, bilateral Chronic

Medication Ketorolac Tromethamine

(L85.3) Xerosis cutis Chronic

Medication Ammonium Lactate

(M06.9) Rheumatoid arthritis, unspecified Chronic

Medication Humira Medication Otrexup

(M45.9) Ankylosing spondylitis of unspecified sites in spine Chronic (E78.5) Hyperlipidemia, unspecified Chronic

Medication Atorvastatin Calcium Stop: 08/19/20

(Z95.9) Presence of cardiac and vascular implant and graft, unspecified

Chronic

(K22.70) Barrett's esophagus without dysplasia Chronic

Medication Omeprazole Stop: 08/19/20

(D50.9) Iron deficiency anemia, unspecified Chronic Comment: lifestyle modification by Jannette Valle on 10/17/19

(I51.9) Heart disease, unspecified Chronic

Medication Losartan Potassium Medication Metoprolol Succinate ER

( Historical ACUITY START STOP )(H20.12) Chronic iridocyclitis, left eye Chronic Comment: Referral to ophthalmologist by Jannette Valle on 10/17/19

(H10.022) Other mucopurulent conjunctivitis, left eye 08/19/2020 Medication Gentamicin Sulfate Stop: 04/24/20

Provider comment: As prescribed by Cardiologist. by Mario Gonzalez-Leyva on 08/19/20

Ergocalciferol 1.25 MG (50000 UT) Oral Capsule

Take 1 capsule (50,000 units) - - by mouth weekly

EScript (verified): 09/11/20 Prescriber: Mario Gonzalez-Leyva SIG: Take 1 capsule (50,000 units) by mouth weekly Refills: 4 Quantity: 4

EScript (verified): 08/19/20 Prescriber: Mario Gonzalez-Leyva SIG: Take 1 capsule (40 mg) by mouth daily 30 minutes before morning meal Refills: 3 Quantity: 30

No immunizations recorded for this patient.

( RECORDED TOBACCO USE Social history )

Current tobacco use

Ex-smoker 10/17/2019

( ALCOHOL USE RECORDED )

1. How often do you have a drink containing alcohol?

Monthly or less

2. How many standard drinks containing alcohol do you have on a typical day?

1 or 2

3. How often do you have 6 or more drinks on 1 occasion?

Never

SCORE

1

This screening is scored 0-12. The higher the score, the more likely a patient's drinking is hazardous.

10/17/2019

( SOCIAL HISTORY (FREE-TEXT) )

( FINANCIAL RESOURCES RECORDED )No social history (free-text) recorded for this patient

( EDUCATION RECORDED )No financial resources recorded for this patient

( PHYSICAL ACTIVITY RECORDED )No education recorded for this patient

( NUTRITION HISTORY RECORDED )No physical activity available for this patient

( STRESS RECORDED )Free Diet

( SOCIAL ISOLATION AND CONNECTION RECORDED )No stress available for this patient

( EXPOSURE TO VIOLENCE RECORDED )No social isolation and connection available for this patient

( GENDER IDENTITY )No exposure to violence history available for this patient

( SEXUAL ORIENTATION )Male

Straight or heterosexual

( Past medical history )

( M A J O R E V E N T S )

Cardiac Cath: operated 2007. Hernia Repair: 1975.

Fistulectomy: operated 1975.

( ONGOING MEDICAL PROBLEMS )RT knee replacement operated 2004 Partial prostatectomy. 2014

( PREVENTIVE CARE )Iron deficiency anemia Rheumatoid arthritis

Preventive Care:

COA: 02/06/2018, 08/19/2020 PHQ-9: 08/19/2020

Short Form IIQ-7: 08/19/2020 Pap smear:

DEXA SCAN:

FOBT: 2/12/2018

Spirometry: 2/5/2018

AAA Screening: Done 2018

EKG: 07/16/2019 Bradycardia/ Sinus bradycardia, performed on 08/19/2020. Colonoscopy: 11/2017

Chest X rays: Ordered 08/19/2020. Chest X rays: There is mild pleural thickening. There is osteopenia of the thoracic vertebrae. Performed 08/28/2020.

Eye exam:

Dental exam:

Vaccines :

Influenza: 04/02/2018. Flu Vaccine was administered on 10/08/2019. CVS Pharmacy. pneumonia

Pneumonia:

( NUTRITION HISTORY )Shingles:

Free Diet

( ONSET DATE DIAGNOSIS Family health history )

No Family health history recorded

( FAMILY HEALTH HISTORY (FREE TEXT) )

Mother died/kidney disease.

Father died / Hemorrhage Ulcer gastric

( Subjective )

HPI: (AWV)

Mr. Fernando Gerdts is a pleasant 71 years old patient, who presents to the o ce today for the annual wellness visit. The patient admits being well, oriented in person, place, and time, with a good appetite. The patient denies any pain or discomfort. He

admits being compensated for chronic diseases. The patient is following all the recommendations regarding treatment and diet. He denies any mental disorder, like anxiety, depression, changes in sleep habits, or changes in thought contents. He is only complaining of occasional low back pain.

The patient denied fever, chills, shortness of breath, chest pain, nausea, or vomiting, or any changes in urine or stools. She looks well in no acute distress at this time. The patient admits to having an adequate house with good family support and is able to perform most of the Activities of Daily Living.

REVIEW OF SYSTEMS:

General: No weight change; no change in strength or exercise tolerance; no fever, chills, or fatigue.

Skin: No new rashes, moles, or lesions, but the skin of the arms is dry.

Head: No headaches, no vertigo, no injury.

Eyes: Normal vision, no diplopia, no tearing, no scotoma, no pain. Ears: No change in hearing, no tinnitus, no bleeding, no vertigo. Nose: No epistaxis, no coryza, no obstruction, no discharge.

Mouth: No dental di culties, no gingival bleeding, no use of dentures.

Neck: No sti"ness, no pain, no tenderness, no noted masses.

Breast: No noted lumps, no tenderness, no swelling, no nipple discharge. Chest: No dyspnea, no wheezing, no hemoptysis, no cough, no sputum. Heart: No chest pain, no palpitations, no syncope, no orthopnea.

GI: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena.

GU: No dysuria, no urgency, clear urines, no hematuria.

Musculoskeletal: Occasional low back pain, no pain in muscles or joints, no limitation of range of motion, He occasional has paresthesias, and numbness in the lower extremities, on the medial aspect of the lower extremities.

Endocrine: No heat or cold intolerance, no excessive/unintentional weight change, no abnormal thirst.

Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.

( Objective )Psychiatric: No depressive symptoms, no suicide or homicide ideation or plan, no changes in sleep habits, no changes in thought content.

PHYSICAL EXAM:

General: male in no acute distress, pleasant and cooperative.

Gait: Normal for the patient's age.

Skin: Normal for patient's age and gender; no rashes, no lesions.

Mucosa: Normal color and moisture.

Head: Normocephalic, no lesions.

Eyes: PERRLA, EOM's full, conjunctiva clear; visual acuity WNL with corrective glasses.

Ears: EAC's clear, TM's normal.

Nose: Mucosa normal, no obstruction.

Throat: Clear, no exudates, no lesions.

Neck: Supple, no masses, no thyroid enlargement, no bruits.

Breast: No skin discoloration or retraction; nipple of normal aspect; no tenderness, no lumps.

Chest: Normal IPP. Auscultation: Good bilateral air entry; no crackles, rhonchi, or wheezes.

Heart: Normal S1, S2; no S3, no S4; no murmurs, no rubs, no gallops.

Abdomen: Normal appearance. No distention, no visible masses, BS normal. Soft, no tenderness, no palpable masses, or enlargement of abdominal organs.

GU: Normal appearance, no lesions, no discharge, no hernias, no masses.

Rectal: Deferred.

Back: Thoracic kyphosis, no paravertebral tenderness; no SIJs tenderness; no sciatic gluteal point tenderness; Neri sign (-).

Musculoskeletal: Well-aligned, no deformities, no swelling, no tenderness, no joint instability, FROM.

Extremities: Well perfused, no edema, no erythema.

Vascular: Peripheral pulses present and symmetric; no varicose veins.

Neurological: Alert, awake and oriented in person, place, and time, no localizing deficit; no tremors, no myoclonic movements.

Psychiatry: Well-groomed, normal mood, and behavior.

Foot examination: No ulcer, no skin maceration, no significant changes in pain/tactile sensation compared to the previous examination.

( Assessment )Depression screening (PHQ-9): Negative for sadness or depressive signs; denies self-harming ideation.

Diagnoses attached to this encounter:

Kyphosis [ICD-10: M40.209], [ICD-9: 737.10], [SNOMED: 414564002]

Bradycardia [ICD-10: R00.1], [ICD-9: 427.89], [SNOMED: 48867003] Rheumatoid arthritis [ICD-10: M06.9], [ICD-9: 714.0], [SNOMED: 69896004]

Ankylosing spondylitis of unspecified sites in spine [ICD-10: M45.9], [ICD-9: 720.0], [SNOMED: 9631008] Hyperlipidemia, unspecified [ICD-10: E78.5], [ICD-9: 272.4], [SNOMED: 55822004]

Coronary bypass graft finding [ICD-10: Z95.9], [SNOMED: 251019006]

Barrett's esophagus without dysplasia [ICD-10: K22.70], [ICD-9: 530.85], [SNOMED: 302914006] Iron deficiency anemia, unspecified [ICD-10: D50.9], [ICD-9: 280.9], [SNOMED: 87522002]

Heart disease, unspecified [ICD-10: I51.9], [ICD-9: 429.9], [SNOMED: 56265001] Chronic uveitis [ICD-10: H20.12], [ICD-9: 364.3], [SNOMED: 444248002]

Age-related osteoporosis without current pathological fracture [ICD-10: M81.0], [ICD-9: 733.00], [ICD-9: 733.01], [SNOMED: 18040001]

Atopic dermatitis of hands [ICD-10: L20.9], [ICD-9: 691.8], [SNOMED: 238541000] Hyperchloremia [ICD-10: E87.8], [ICD-9: 276.9], [SNOMED: 74450001]

Hypernatremia [ICD-10: E87.0], [ICD-9: 276.0], [SNOMED: 771115008] Anemia [ICD-10: D64.9], [ICD-9: 285.9], [SNOMED: 271737000]

Chronic iridocyclitis, bilateral [ICD-10: H20.13], [ICD-9: 364.10], [SNOMED: 398155003] Xerosis cutis [ICD-10: L85.3], [ICD-9: 706.8], [SNOMED: 89105000]

Candidiasis of skin and nail [ICD-10: B37.2], [ICD-9: 112.3], [SNOMED: 49883006], [SNOMED: 23484007]

( Plan )

THERAPEUTIC PLAN: (AWV) I have the pleasure of having the patient in my o ce today for the Annual Wellness Examination. I have discussed with the patient the diagnoses and plan of care at length; given the opportunity to ask questions, which are answered until full understanding acknowledged.

Health Questionnaires:

-COA: Performed 08/19/2020.

-Incontinence Impact, Short form IIQ-7: Performed 08/19/2020.

-Depression screening, PHQ-9: Performed 08/19/2020.

BMI assessed and documented in the chart.

Depression screening performed for 15 minutes and documented in the chart.

Risk factors reviewed.

Advanced Care Planning: Discussed with the patient. Documented in the chart.

Pain screening performed: Severity assessed and documented in the chart. Urinary Incontinence screening: performed and documented in the chart. Screening for alcohol, tobacco, and recreational use/abuse: done.

Screening for unprotected sexual activity/STDs & HIV risks: done.

Functional Status Assessment: performed & documented in the chart.

Fall Risk Assessment performed & documented in the chart.

Diagnostic studies:

Lab work: CBC, CMP, Lipid panel, Coagulation tests, vitamin B12, folate, and Vitamin D levels, Tumor markers, Homocysteine level,

Urinalysis, Thyroid profile: were ordered. Blood and urine specimens were collected today and sent to LabCorp.

Image studies: Chest X rays and Bladder/ Prostate US with post-void residual volume was ordered.

Other studies; EKG was performed today in the o ce. a Sinus Rhythm with Bradycardia is noted in the tracings.

Other studies: Previous work up results explained in detail to the patient; understood well.

MEDICATIONS: Medications list reviewed and reconciled; verified and discussed with the patient in detail; understood and agreed. The list subsequently documented in the chart. Continue baseline medications.

Addition/changes: Omeprazole 40 mg PO daily before breakfast. Monitor tolerance, reaction, and e"ectiveness of medications. The patient was advised to comply with the medication regime.

Counseled about medication compliance: Advised about severe health risks of skipping/missing doses of medications. Counseled about the importance of regular blood pressure checking. Keep the BP log as instructed until the next visit. DIET: Low salt & low fat. Counseled about healthy eating. Avoid fatty and fried food.

BMI Management: Overweight & Obesity counseling provided. I strongly advised the patient to lose weight. The patient made aware of obesity's health risks as well as the benefits of losing weight. Attempt weight loss through improved eating habits,

discussion of healthy foods, and avoidance of unhealthy ones.

Encouraged to increase physical activity and exercise regularly within physical capacity. Patient understood.

Activity: Increase and maintain physical activity for physical and emotional health, as well as improvement of chronic illnesses.

Falling precautions advised.

Sunbathing at least 15-20 minutes twice a day.

PLAN FOR HYPERLIPIDEMIA

-Take lipid-lowering agents as prescribed.

-Initiate a total lifestyle change, including a healthy diet, physical exercises, weight control, proper sleep hygiene, and nonstressful situations.

-Recommended low cholesterol diet and low triglycerides diet.

-It is recommended to drink plenty of fluids.

-Increase intake of fruits, vegetables, grains, and fiber-rich foods.

-Take OTC Omega 3 as instructed.

-Follow a weight management program.

-Increase physical activity.

-Control Blood pressure and adhere to antihypertensive medications.

-Avoid cigarette smoking.

PLAN FOR HYPERTENSION

-Continue with prescribed antihypertensive medications and be compliant.

-Perform home blood pressure checks and complete a diary if abnormal blood pressure or heart rate.

-Avoid cigarette smoking.

-Increase aerobic physical activity to at least 30 minutes per day, 3 days per week.

-Reduce or maintain weight to a BMI goal of 18.5 to 24.9 kg/m2.

-Reduce dietary sodium intake to less than 2.4 g/day

-Avoid or minimize alcohol and ca"eine beverages intake.

-Avoid stressful situations.

-Practice proper sleep hygiene.

-Avoid medication overuse, particularly NSAIDs.

PREVENTIVE MEASURES FOR CORONAVIRUS AND OTHER RESPIRATORY INJECTIONS

-Wash your hand frequently with soap and water, or

-Regularly and thoroughly clean your hands with an alcohol-based hand sanitizer.

-Maintain social distancing. The patient was recommended to maintain at least 1-meter distance with anyone who is coughing or sneezing.

-Avoid touching eyes, nose, and mouth.

-Practice respiratory hygiene, and make sure that people around the patient, follow good respiratory hygiene. This means covering the mouth and nose with the bent elbow or tissue when cough or sneeze. Then dispose of the used tissue immediately.

-Stay home if you feel unwell and contact the o ce immediately.

-If you have a fever, cough, and di culty breathing, seek medical attention, and call in advance.

-Follow the directions of the local health authorities.

-Stay informed and follow the advice given by your healthcare provider

The preventive measures for Coronavirus infection were discussed. An EKG was done in the o ce today: Reported

Venipuncture for lab tests was done in the o ce today. Next appointment in 2 weeks or sooner as needed.

Medications attached to this encounter:

Humira 40 MG/0.8ML Subcutaneous Prefilled Syringe Kit Administer 0.8 ml (40 mg) subcutaneously every 14 days Vitamin C 500 MG Oral Capsule 1 tab PO a day

Aspirin 81 MG Oral Tablet Chewable Chew and swallow 1 tablet (81 mg) by mouth daily Ketorolac Tromethamine 0.4 % Ophthalmic Solution 1 drop into a"ected eye one time Losartan Potassium 25 MG Oral Tablet Take 1 tablet (25 mg) by mouth daily

Otrexup 17.5 MG/0.4ML Subcutaneous Solution Auto-injector Administer 0.4 ml (17.5 mg) subcutaneously one time for arthritis

Metoprolol Succinate ER 25 MG Oral Tablet Extended Release 24 Hour Take 1 tablet (25 mg) by mouth daily Ammonium Lactate 12 % External Cream 1 application topically to a"ected area 2 times per day Atorvastatin Calcium 40 MG Oral Tablet Take 1 tablet (40 mg) by mouth daily

( Screenings/ Interventions/ Assessments )Omeprazole 40 MG Oral Capsule Delayed Release Take 1 capsule (40 mg) by mouth daily 30 minutes before morning meal

No screenings/interventions/assessments recorded.