unit 4 assigment
aq24
fallriskpt.docx_67 y.o._ _male_ who presents to the office today for a follow up of their chronic conditions as detailed below.
Hyperlipidemia
Well controlled on rosuvastatin 20mg.
Shortness of Breath/COPD
+DOE, Has albuterol neb/inhaler but doesnot use, feels they do not help Chronic-no worse than normal. No recent flares. Follows with respiratory. Continues on Spiriva, Wixela. Refer to consult notes. Interested in RSV vaccine.
Sleep apnea - sees respiratory specialists compliant with CPAP
Lung Ca-continues to follow with CTS & Hem/Onc. gets CT lungs every 3 months-Recent CT stable
Multilevel degenerative disc disease comes and goes. No longer working, retired. Takes Ibuprofen with adequate relief.
Follows with Reading dermatology-has a new area on shoulder that is precancerous and will be excised in December.
Glucose elevated, 111. Pt was fasting +family history.
Continues to have anxiety especially when going to appointment Ativan is effective.
HTN-BP elevated 138/92. Reports it has been trending up. Tries to watch sodium.
UTD with eye and dental exams
Interested in RSV vaccine
Having trouble hearing especially when a lot of background noise. Sees ENT, just watching for now.
Drinking alcohol daily 6 beers daily average. Does not feel he has a problem.
Live alone.Enjoys hunting, has a wood shop he enjoys. Not exercising regularly. Feels his diet has been poor.
The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history and problem list.
_Review of Systems
Constitutional: Negative for fever.
HENT: Positive for hearing loss.
Respiratory: Negative for hemoptysis and shortness of breath (+ dyspnea on exertion).
Cardiovascular: Negative for chest pain, palpitations and leg swelling.
Gastrointestinal: Negative for abdominal pain, constipation and diarrhea.
Genitourinary: Negative.
Musculoskeletal: Positive for back pain.
Skin:
Lesion right shoulder/back
Neurological: Negative.
Endo/Heme/Allergies: Negative for polydipsia. Bruises/bleeds easily.
Psychiatric/Behavioral: The patient is nervous/anxious.
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OBJECTIVE:
Vitals: _BP (!) 138/92 (Site: Left upper arm, Position: Sitting) | Pulse 77 | Temp 36.5 °C (97.7 °F) (Temporal/Forehead) | Resp 20 | Wt 264 lb (119.7 kg) | SpO2 94% Comment: room air | BMI 38.97 kg/m² _
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_ Wt Readings from Last 3 Encounters: |
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11/24/23 |
264 lb (119.7 kg) |
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11/13/23 |
264 lb 4.8 oz (119.9 kg) |
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05/23/23 |
256 lb (116.1 kg) |
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_ Physical Exam Vitals and nursing note reviewed.
Constitutional:
General: He is not in acute distress.
Appearance: Normal appearance. He is obese.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane, ear canal and external ear normal.
Left Ear: Tympanic membrane, ear canal and external ear normal.
Nose: Nose normal.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.
Eyes:
Extraocular Movements: Extraocular movements intact.
Pupils: Pupils are equal, round, and reactive to light.
Neck:
Musculoskeletal: Normal range of motion.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Abdominal:
General: Abdomen is flat. Bowel sounds are normal.
Palpations: Abdomen is soft.
Musculoskeletal:
Cervical back: Normal range of motion.
Right lower leg: No edema.
Left lower leg: No edema.
Neurological:
General: No focal deficit present.
Mental Status: He is alert and oriented to person, place, and time.
Skin:
General: Skin is warm and dry.
Capillary Refill: Capillary refill takes less than 2 seconds.
Psychiatric:
Mood and Affect: Mood and affect normal.
Behavior: Behavior normal.
Thought Content: Thought content normal. Thought content does not include homicidal or suicidal ideation. Thought content does not include homicidal or suicidal plan.
Judgment: Judgment normal.
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Labs:
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_ Lab Results |
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Component |
Value |
Date |
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WBC |
5.4 |
11/07/2023 |
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HGB |
15.2 |
11/07/2023 |
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HCT |
44.4 |
11/07/2023 |
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PLT |
201 |
11/07/2023 |
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CHOL |
158 |
11/07/2023 |
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TRIG |
54 |
11/07/2023 |
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HDL |
54 |
11/07/2023 |
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LDLCAL |
93.2 |
11/07/2023 |
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ALT |
32 |
11/07/2023 |
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AST |
32 |
11/07/2023 |
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NA |
138 |
11/07/2023 |
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K |
4.1 |
11/07/2023 |
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CL |
104 |
11/07/2023 |
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CREATININE |
0.88 |
11/07/2023 |
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BUN |
16 |
11/07/2023 |
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CO2 |
25.9 |
11/07/2023 |
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TSH |
1.067 |
11/07/2023 |
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PSA |
<0.1 |
05/12/2020 |
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INR |
1.0 |
02/03/2021 |
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ASSESSMENT / PLAN:
_Carl was seen today for follow-up.
Diagnoses and all orders for this visit:
Chronic obstructive pulmonary disease, unspecified COPD type (HCC)
Anxiety state
Squamous cell cancer of scalp and skin of neck
Essential hypertension
- CBC and Differential; Future
- Comprehensive Metabolic Panel; Future
- Hemoglobin A1c; Future
- LIPID PANEL; Future
- lisinopriL (PRINIVIL) 20 MG tablet; Take 1 tablet (20 mg total) by mouth daily.
Impaired fasting glucose
- Hemoglobin A1c; Future
Depression screen
- Negative for Depression Screening
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Routine health maintenance:
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_ Health Maintenance |
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Topic |
Date Due |
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COPD CAT Score Yearly |
11/23/2023 |
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Annual Medicare Wellness |
11/24/2023 |
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Colorectal Cancer Screen |
05/07/2024 |
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Pneumococcal Polysaccharide 65+ years (3 - PPSV23 or PCV20) |
03/29/2024 |
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Depression Screening |
05/24/2024 |
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Fall Risk Assessment |
11/24/2024 |
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Hepatitis C Screening |
Completed |
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COPD PFT |
Completed |
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Influenza Vaccine |
Completed |
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ABDOMINAL AORTIC ANEURYSM (AAA) SCREEN |
Completed |
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Zoster/Shingrix |
Completed |
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Covid-19 Vaccine |
Completed |
_Check A1C with next labs.
Increase Lisinopril to 20mg daily.
RSV will get at the pharmacy.
Continue current medications and treatment plans except where noted.
Follow Up: _No follow-ups on file._
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Diagnosis |
Date |
Comment |
Source |
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Anxiety |
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Asthma |
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CA - cancer of prostate |
11/16/2011 |
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Cancer (HCC) |
2013 |
Prostate - tx surgery with Dr Henry |
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Chronic obstructive pulmonary disease (HCC) |
8/2/2012 |
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COPD (chronic obstructive pulmonary disease) (HCC) |
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Depression |
12/9/2012 |
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Elevated serum cholesterol |
3/14/2012 |
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Glaucoma |
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Hyperlipidemia |
8/2/2012 |
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Hypertension |
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Low back syndrome |
3/14/2012 |
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Lung cancer (HCC) |
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lisinopril
20 mg Oral Daily
10 mg Oral Daily
lorazepam
0.5 mg Oral Every 6 hours PRN
(Dose adjustment)
Visit Diagnoses
Chronic obstructive pulmonary disease, unspecified COPD type (HCC) J44.9
Anxiety state F41.1
Squamous cell cancer of scalp and skin of neck C44.42
Essential hypertension I10
Impaired fasting glucose R73.01
Depression screen Z13.31
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albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulizer solution |
USE CONTENTS OF 1 VIAL VIA NEBULIZER EVERY 6 HOURS IF NEEDED FOR WHEEZING |
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Inhale 2 puffs into the lungs every 6 (six) hours as needed for Wheezing. |
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Takes every other day |
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fluticasone propion-salmeteroL (WIXELA INHUB) 500-50 mcg/dose DsDv diskus inhaler |
Inhale 1 puff into the lungs. |
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fluticasone propionate (FLONASE) 50 mcg/actuation nasal spray |
2 sprays each nostril daily; may substitute with generic |
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Take 1 tablet (800 mg total) by mouth daily with breakfast. |
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Take 1 tablet (20 mg total) by mouth daily. |
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Take 1 tablet (0.5 mg total) by mouth every 6 (six) hours as needed for Anxiety. |
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Take 1 tablet by mouth daily. One daily |
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Take 1 tablet (20 mg total) by mouth daily. |
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Take 1 tablet (100 mg total) by mouth daily. |
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tiotropium bromide (SPIRIVA RESPIMAT) 2.5 mcg/actuation inhaler |
INHALE 2 PUFFS BY MOUTH ONCE EVERY DAY **NOTE NEW DOSAGE AND NEW INHALER DIRECTIONS** |
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TAKE 1 TABLET (10 MG TOTAL) BY MOUTH DAILY. |
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Take 1 tablet (0.5 mg total) by mouth every 6 (six) hours as needed for Anxiety. |
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TAKE 1 TABLET BY MOUTH ONCE DAILY |
