Module 3 medical terminology

Chief complaint

Lethargy and weight gain

PATIENT Jaclyn M DeMonte DOB 10/21/1985 AGE 31 yrs SEX Female PRN JE742116

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 02/05/2017 AGE AT DOS

31 yrs

Not signed

Patient identifying details and demographics

FIRST NAME Jaclyn MIDDLE NAME M LAST NAME DeMonte SSN -

SEX Female DATE OF BIRTH 10/21/1985 DATE OF DEATH - PRN JE742116

ETHNICITY Not Hispanic or Latino

PREF. LANGUAGE

English

RACE White,Asian STATUS Active patient

CONTACT INFORMATION

ADDRESS LINE 1 323 Elast Drive ADDRESS LINE 2 - CITY Brownsville STATE PA ZIP CODE 49300

CONTACT BY Home Phone EMAIL Jaclyn.demonte@

testpatient.com HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE - OFFICE EXTENSION

-

FAMILY INFORMATION

NEXT OF KIN Marie Demonte RELATION TO PATIENT Mother PHONE 5555555555 ADDRESS -

PATIENT'S MOTHER'S MAIDEN NAME

-

Encounter - Office Visit Date of service: 02/05/17 Patient: Jacl... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

1 of 5 4/6/17, 3:40 PM

Active Medications

MEDICATION SIG START/STOP ASSOCIATED DX

Levothyroxine Sodium (Levoxyl) 100 MCG Oral Tablet

04/06/17 - Hypothyroidism

Historical Medications

MEDICATION SIG START/STOP ASSOCIATED DX

Ampicillin 250 mg oral capsule 04/10/14 - 05/10/14

-

Penicillin V Potassium 250 MG Oral Tablet

05/01/14 - 10/06/16

Chronic sinusitis

Smoking History

STATUS EFFECTIVE DATE

Former smoker 04/06/2008

Encounter - Office Visit Date of service: 02/05/17 Patient: Jacl... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

2 of 5 4/6/17, 3:40 PM

No Family health history recorded

Past medical history

MAJOR EVENTS

Fx radius- 1998 Septoplasty- December 2002 Acute pancreatitis- July 2006 Pregnancy and vaginal birth- November 2013 Hospitalized with abdominal px due to IBS- 2014

ONGOING MEDICAL PROBLEMS

Irritable Bowel Syndrome- In remission currently Seasonal allergies

FAMILY HEALTH HISTORY

Mother- Irritable Bowel Syndrome, pancreatitis, Addison disease Father- CVD, Type II diabetes Maternal GM- Stroke, Thyroid disease Maternal GF- Died of myocardial infarction Paternal GM- Cushing syndrome, Died of complications of thyroid cancer Paternal GF- Unknown Two maternal aunts diagnosed with breast cancer

PREVENTIVE CARE

Avoids allergens, controls IBS with strict diet

SOCIAL HISTORY

Nonsmoker. Quit in 2008.

NUTRITION HISTORY

Restricts seafood due to allergy. High fiber diet helps to regulate IBS symptoms. Small, frequent meals. Describes her diet as "mostly vegan".

Family health history

DIAGNOSIS ONSET DATE

Subjective

HPI Jacyln presents today complaining of lethargy and weight gain. She has not changed her diet, nor exercise routine. She denies night sweats, or chills, She denies visual changes, headache, neck pain, or nuchal rigidity. She had a septoplasty a half-decade ago for a deviated septum and reports that it was successful and had increased her ease of breathing. She reports seasonal allergies. She works as a dental hygienist are denies any recent trauma or lifestyle changes.

Review of Systems Constitutional: per HPI

Encounter - Office Visit Date of service: 02/05/17 Patient: Jacl... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

3 of 5 4/6/17, 3:40 PM

HEENT: Prior septoplasty for chronic sinusitis resistant to 4 weeks of ampicillin treatment. Patient reports head cold 7 weeks ago. Her PCP ruled out mononucleosis and treated with 1 g of ampicillin daily for 4 weeks. Today, she still reports nasal congestion, drainage, low grade subjective fevers, and facial pain. Respiratory: Congestion due to sinusitis Cardiovascular: negative Gastrointestinal: occasional epigastric abdominal pain associated with IBS Genitourinary: negative Musculoskeletal: negative Endocrine: Lethargy, weight gain

Objective

PHYSICAL EXAM:

General: Sitting up, concerned. Swollen appearance. Pale face. Weight gain of 12 pounds since last visit 4 months ago.

Head & Neck: No anterior or posterior cervical or auricular lymphadenopathy, maxillary sinuses tender bilaterally to light tapping. Enlarged, tender thyroid gland

Eyes & Ears: PEERL. Tympanic membranes normal appearing without inflammation, erythema. Normal light reflex.

Oral Cavity: Posterior pharynx is mildly erythematous.

Cadiovascular: No complaints.

Gastrointestinal: No complaints of dysphagia, nausea, vomiting, or change in stool pattern, consistency, or color. She complains of epigastric pain, burning in quality, approximately twice a month, which she notices primarily at night.

Genitourinary: No complaints of dysuria, nocturia, polyuria, hematuria, or vaginal bleeding.

Musculoskeletal: She complains of widespread aching within the last 4 months. She complains of no other arthralgias, muscle aches, or pains.

Neurological: She reports occasional disorientation.

Assessment

DDX: Hypothyroidism

Diagnoses attached to this encounter:

(E03.9) Hypothyroidism, unspecified Acute

Plan

Order CBC, Thyroid panel, Ultrasound of thyroid gland. Pending results of lab tests- Levoxyl BID Referral to specialist may be necessary. Will discuss this during follow-up visit.

Medications attached to this encounter:

Levothyroxine Sodium (Levoxyl) 100 MCG Oral Tablet

Encounter - Office Visit Date of service: 02/05/17 Patient: Jacl... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

4 of 5 4/6/17, 3:40 PM

Free cloud based EHR

Encounter - Office Visit Date of service: 02/05/17 Patient: Jacl... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

5 of 5 4/6/17, 3:40 PM