Module 6

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PATIENT Nancy R Jackson-Davis DOB 04/08/1982 AGE 35 yrs SEX Female PRN NO731672

FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999

Patient identifying details and demographics

FIRST NAME Nancy MIDDLE NAME R LAST NAME Jackson-Davis SSN -

SEX Female DATE OF BIRTH 04/08/1982 DATE OF DEATH - PRN NO731672

ETHNICITY Not Hispanic or Latino

PREF. LANGUAGE

English

RACE Black or African American,Asian

STATUS Active patient

CONTACT INFORMATION

ADDRESS LINE 1 321 S. 54th St ADDRESS LINE 2 - CITY Anytown STATE NY ZIP CODE 12345

CONTACT BY Home Phone EMAIL [email protected]

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

-

FAMILY INFORMATION

NEXT OF KIN Scott Davis RELATION TO PATIENT Spouse PHONE 5555555555 ADDRESS 345 56th St

Anytown, NY 12345

PATIENT'S MOTHER'S MAIDEN NAME

Halifax

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

1 of 10 4/8/17, 9:18 AM

Vitals flowsheet - Nancy R Jackson-Davis

02/08/17 7:35 AM

03/06/17 7:44 AM

03/31/17 2:00 AM

Vitals

Height 62 in 62 in 62 in

Weight 145 lb 142 lb 137.99 lb

BMI 26.52 25.97 25.24

BMI Percentile

BP 138/68 mmHg 126/67 mmHg 125/88 mmHg

Temperature 98.4 °F 98.6 °F 98.9 °F

Pulse 76 bpm 68 bpm 76 bpm

Respiratory rate 14 bpm 16 bpm 10 bpm

O2 Saturation

Pain

Head Circumference

Chronic Diagnoses

ACTIVE DIAGNOSES START STOP

(K58.0) Irritable bowel syndrome with diarrhea 02/08/2017

Medication Viberzi Start: 04/08/17

(K21.9) Gastro-esophageal reflux disease without esophagitis 02/08/2017

Medication Omeprazole Medication Omeprazole Start: 03/06/17

(K44.9) Diaphragmatic hernia without obstruction or gangrene 02/08/2017

HISTORICAL DIAGNOSES START STOP

(Z33.1) Finding related to pregnancy 07/04/2009 04/16/2010

Acute Diagnoses

ACTIVE DIAGNOSES START STOP

(K59.00) Constipation, unspecified 03/06/2017

HISTORICAL DIAGNOSES START STOP

(O20.0) Threatened abortion, antepartum condition or complication 07/17/2014 07/17/2014

(N36.9) Unspecified disorder of urethra and urinary tract 02/08/2014 02/08/2014

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

2 of 10 4/8/17, 9:18 AM

Drug Allergies

ACTIVE ALLERGIES SEVERITY/REACTIONS ONSET

Patient has no known drug allergies

Food Allergies

ACTIVE ALLERGIES SEVERITY/REACTIONS ONSET

No food allergies recorded

Environmental Allergies

ACTIVE ALLERGIES SEVERITY/REACTIONS ONSET

No environmental allergies recorded

Active Medications

MEDICATION SIG START/STOP ASSOCIATED DX

Eluxadoline (Viberzi) 75 MG Oral Tablet

04/08/17 - IBS with diarrhea

Omeprazole 10 MG Oral Capsule Delayed Release

- GERD

Provider comment: b.i.d. by Nazir Ashaad on 04/08/17

Omeprazole 20 MG Oral Capsule Delayed Release

03/06/17 - GERD

Smoking History

STATUS EFFECTIVE DATE

No smoking history available for this patient

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

3 of 10 4/8/17, 9:18 AM

Past medical history

MAJOR EVENTS

Appendectomy (1992) Fx radius and ulna (1998) Pregnancy and vaginal delivery (2010)

ONGOING MEDICAL PROBLEMS

Hiatal hernia- Dx 2016; Monitoring, no tx to date

FAMILY HEALTH HISTORY

Father- Hypertension, hypercholesterolemia Mother- Celiac disease PGM- died of lung cancer PGF- alive and in good health MGM- Rheumatoid arthritis, inguinal hernia, unspecified bowel issues MGF- Cardiovascular disease, stroke

PREVENTIVE CARE

Pap smears - no hx abnormal pap smear Vaccinations: Yearly influenza (most recent 2016) DPT (2009) Hepatitis B (approx 1996)

SOCIAL HISTORY

Married with one child. Reports safe, stable family environment. Does not use alcohol, tobacco, other drugs. Occupation: social worker

NUTRITION HISTORY

No current restrictions in diet.

DEVELOPMENTAL HISTORY

Normal

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

4 of 10 4/8/17, 9:18 AM

Chief complaint

Epigastric px, nausea, vomiting

Vitals for this encounter

No vitals recorded

PATIENT Nancy R Jackson-Davis DOB 04/08/1982 AGE 35 yrs SEX Female PRN NO731672

FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999

ENCOUNTER Office Visit NOTE TYPE SOAP Note SEEN BY Nazir Ashaad DATE 04/08/2017 AGE AT DOS

35 yrs

Not signed

SUBJECTIVE

The patient returns for followup. She relates she has been doing well, except that since February, she has had epigastric pain. She took omeprazole first once daily and then b.i.d. and felt somewhat better. She took it for about a month and then tapered to off. Last week, she had an episode of hematemesis with bright red blood. She reports she was not retching prior to the hematemesis. She had a dark stool, but no frank melena after that.

OBJECTIVE

Abdomen: Positive bowel sounds with mild epigastric tenderness. No rebound or guarding. No peritoneal signs. Rectal Exam: No masses and brown Hemoccult-negative stool.

ASSESSMENT

Epigastric pain with an episode of hematemesis.

Diagnoses attached to this encounter:

(K58.0) Irritable bowel syndrome with diarrhea

PLAN

Recommend an upper endoscopy and order was put through for the same. The patient has no signs of active bleeding and is currently Hemoccult negative from below. Restart omeprazole b.i.d. Check liver tests, CBC, amylase, lipase, and a pregnancy test.

Medications attached to this encounter:

Eluxadoline (Viberzi) 75 MG Oral Tablet

Omeprazole 10 MG Oral Capsule Delayed Release

Free cloud based EHR

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

5 of 10 4/8/17, 9:18 AM

Chief complaint

No chief complaint recorded

PATIENT Nancy R Jackson-Davis DOB 04/08/1982 AGE 35 yrs SEX Female PRN NO731672

FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999

ENCOUNTER Office Visit NOTE TYPE SOAP Note SEEN BY Nazir Ashaad DATE 03/06/2017 AGE AT DOS

34 yrs

Not signed

Vitals for this encounter

03/06/17 7:44 AM

Height 62 in

Weight 142 lb

Temperature 98.60 °F

Pulse 68 bpm

Respiratory rate 16 bpm

BMI 25.97

Blood pressure 126/67 mmHg

SUBJECTIVE

The patient is a pleasant 34-year-old female who presents today in gastroenterology clinic for followup of nausea, vomiting, and reflux. The patient has been taking omeprazole twice per day and ranitidine at bedtime. Her reflux has returned about 2x/week. She had isolated episodes of vomiting. Constipation is new symptom that has been occurring over the past 4 days.

OBJECTIVE

Pain score 4/10 in the abdomen. Tenderness upon abdominal palpation in all four quadrants.

ASSESSMENT

Hiatal hernia seems to be stable. Reflux is no longer controlled by current dosage of omeprazole. Constipation needs to be addressed.

Diagnoses attached to this encounter:

(K59.00) Constipation, unspecified Acute

(K58.0) Irritable bowel syndrome with diarrhea

PLAN

Start viberzi q.i.d. Continue omeprazole. Increase dosage to 20 MG. Short term suppository laxative recommended.

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

6 of 10 4/8/17, 9:18 AM

Reassess effectiveness of medication change in one month.

Medications attached to this encounter:

Eluxadoline (Viberzi) 75 MG Oral Tablet

Omeprazole 20 MG Oral Capsule Delayed Release

Free cloud based EHR

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

7 of 10 4/8/17, 9:18 AM

Chief complaint

Abdominal pain, nausea, diarrhea

PATIENT Nancy R Jackson-Davis DOB 04/08/1982 AGE 35 yrs SEX Female PRN NO731672

FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999

ENCOUNTER Office Visit NOTE TYPE SOAP Note SEEN BY Nazir Ashaad DATE 02/08/2017 AGE AT DOS

34 yrs

Not signed

Vitals for this encounter

02/08/17 7:35 AM

Height 62 in

Weight 145 lb

Temperature 98.40 °F

Pulse 76 bpm

Respiratory rate 14 bpm

BMI 26.52

Blood pressure 138/68 mmHg

SUBJECTIVE

The patient is a pleasant 34-year-old female who presents today in gastroenterology clinic for followup of nausea, vomiting, and reflux.

HPI She complains of sharp, epigastric abdominal pain of 3-4 months duration. The abdominal pain has been gradually worsening over the past 3-4 months. The pain has not changed or worsened acutely. The pain is located in the epigastric region and left upper quadrant of the abdomen. It does not radiate. The pain is relatively constant throughout the day and night but does vary in severity. She rates the pain as 6/10 at its worst. She describes the pain as a “sharp, burning” pain. She has not tried taking any medicines to relieve the pain. The pain is not alleviated with rest. She thinks the pain may be aggravated by throwing the football, but he has also experienced the pain independent of playing football or exerting herself. The pain is not associated with a particular food or eating, although she does endorse occasional heartburn. She reports the pain may at times be worse on laying down, and it does wake her up at night. She denies any abdominal trauma or injury. She endorses a 5lb weight loss over the past 3-4 months, decreased appetite, and fatigue. She has experienced some nausea with the abdominal pain and has occasionally vomited.

ROS General: Pleasant female in no acute distress. HEENT: Not examined Lymph nodes: Non-tender, no palpable masses Neck: No masses Cardiovascular: See vitals.

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

8 of 10 4/8/17, 9:18 AM

Lungs: Lungs clear to auscultation bilaterally; No wheezes or crackles Abdominal:

Abdomen soft and non-distended with no scars or striations No pulsatile masses, no abdominal bruits ascultated Spleen not palpable, liver not palpable Tender to palpation in epigastric region and left upper quadrant; No reflex tenderness; No guarding; Murphy’s sign negative

Genitourinary: No complaints of dysuria, nocturia, polyuria, hematuria, or vaginal bleeding. Musculoskeletal: She complains of lower back pain, aching in quality, approximately once every week after working in her garden. This pain is usually relieved with Tylenol. She complains of no other arthralgias, muscle aches, or pains. Neurological: She complains of no weakness, numbness, or incoordination.

OBJECTIVE

PE General: Patient appears alert, oriented and cooperative.

Skin:Normal in appearance, texture, and temperature HEENT: Scalp normal. Pupils equally round, 4 mm, reactive to light and accommodation, sclera and conjunctiva normal. Fundoscopic examination reveals normal vessels without hemorrhage. Tympanic membranes and external auditory canals normal. Nasal mucosa normal. Oral pharynx is normal without erythema or exudate. Tongue and gums are normal.

Neck: Easily moveable without resistance, no abnormal adenopathy in the cervical or supraclavicular areas. Trachea is midline and thyroid gland is normal without masses. Carotid artery upstroke is normal bilaterally without bruits. Jugular venous pressure is measured as 8 cm with patient at 45 degrees.

Chest: Lungs are clear to auscultation and percussion bilaterally.

Abdomen: The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right paraumbilical area. No masses or splenomegaly are noted; liver span is 8 cm by percussion.

Extremities: No cyanosis, clubbing, or edema are noted. Peripheral pulses in the femoral, popliteal, anterior tibial, dorsalis pedis, brachial, and radial areas are normal.

Nodes: No palpable nodes in the cervical, supraclavicular, axillary or inguinal areas.

Genital/Rectal: Normal rectal sphincter tone; no rectal masses. Stool is brown. Pelvic examination reveals normal external genitalia, and normal vagina and cervix on speculum examination. Bimanual examination reveals no palpable uterus, ovaries, or masses.

Neurological: Cranial nerves II-XII are normal. Motor and sensory examination of the upper and lower extremities is normal. Gait and cerebellar function are also normal. Reflexes are normal and symmetrical bilaterally in both extremities.

ASSESSMENT

DDX: IBS with diarrhea GERD

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

9 of 10 4/8/17, 9:18 AM

Diagnoses attached to this encounter:

(K58.0) Irritable bowel syndrome with diarrhea

(K21.9) Gastro-esophageal reflux disease without esophagitis

(K44.9) Diaphragmatic hernia without obstruction or gangrene

PLAN

Start omeprazole b.i.d. Monitor IBS symptoms over next month to assist in diagnosis. Food journal will be discussed at next visit.

The patient at this point will follow up in one month. She is encouraged that if symptoms worsen in the interim, she should contact us. We did also discuss seeing a surgeon for repairing the hiatal hernia. However, at this point, the patient’s symptoms are well controlled on medication and that does not appear necessary.

Medications attached to this encounter:

Omeprazole 10 MG Oral Capsule Delayed Release

Free cloud based EHR

Patient chart - Patient: Nancy R Jackson-Davis DOB: 04/08/19... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

10 of 10 4/8/17, 9:18 AM

Vendor Order 1704Q0Y0 added on 04/08/17 Other

PATIENT Nancy R Jackson-Davis DOB 04/08/1982 AGE 35 yrs SEX Female PRN NO731672

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 02/08/2017 AGE AT DOS

34 yrs

Not signed

Orders

LAB ORDERS

1625 - Occult Blood, Fecal, IA

IMAGING ORDERS

No orders attached to this encounter.

Free cloud based EHR

Encounter - Office Visit Date of service: 02/08/17 Patient: Nan... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

1 of 1 4/8/17, 3:35 PM

Vendor Order 1704Q0YZ added on 04/08/17 Other

Imaging Order 1704Q0YF added on 04/08/17 Other

PATIENT Nancy R Jackson-Davis DOB 04/08/1982 AGE 35 yrs SEX Female PRN NO731672

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 04/08/2017 AGE AT DOS

35 yrs

Not signed

Orders

LAB ORDERS

3638 - CBC W Auto Differential panel - Blood

44 - Lipase serum or plasma

68 - Amylase serum or plasma

94 - hCG (Pregnancy Test)

IMAGING ORDERS

1064 - Fluoroscopy Guidance for endoscopy of Stomach

Free cloud based EHR

Encounter - Office Visit Date of service: 04/08/17 Patient: Nan... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...

1 of 1 4/8/17, 3:34 PM

Northstar Imaging Center

2345 Sunshine Way #200

Minneapolis, MN 99999

Phone: (555) 555-5555

Patient: Nancy Jackson-Davis

DOB: 04/08/1982

RELEVANT CLINICAL HISTORY S&S: Epigastric px, nausea, vomiting, single episode of hematemesis Symptoms have persisted for several months with periods of remission. Most recently, patient experienced an episode of hematemesis, consisting of bright red blood. Fecal occult blood test negative. PROCEDURE PERFORMED: Exploratory upper endoscopy PROCEDURE INDICATION: Patient is a 35-year-old female. An endoscopy is being performed to evaluate for source of upper GI bleeding. MEDICATIONS Topical Cetacaine spray delivered preoperatively. Throughout the procedure, IV Fentanyl 100 mcg in incremental fashion with careful monitoring of patient's vital signs. PROCEDURE IN DETAIL: Informed consent was obtained and risks, benefits and alternatives of the procedure were explained. The patient agreed to proceed. The patient was placed in the left lateral decubitus position. Medications were delivered as described above. Upon achieving adequate sedation, the Olympus video endoscope was inserted orally, over the dorsum of the tongue, and advanced through the pharynx, esophagus, and stomach until reaching the duodenum. The duodenum appeared normal. The scope was then retracted to view the stomach. The antrum and angularis appeared normal as well. The scope was retroflexed to visualize the entirety of the stomach, including the rugal folds, body, and fundus of the stomach. Visualization of the body of the stomach revealed a 3 cm diameter ulcer on the posteroinferior wall. Retroflexion view of the fundus of the stomach showed evidence of a hiatal hernia, which was previously noted. The scope was then anteflexed and retracted to view the distal esophagus. The esophagus showed no evidence of stricture, neoplasm, or ulceration. Samples were obtained from the antrum to screen for Helicobacter and additional samples were sent to pathology. The LES and remaining portion of the esophagus appeared normal. The squamocolumnar junction appeared normal as well. The scope was then slowly removed and the procedure terminated. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: 1. Hiatal hernia, as previously noted. 2. Type IV gastric ulcer- 3 cm diameter on posteroinferior body of stomach. 3. No esophageal abnormalities noted. Physician’s Signature Derek A. Sandbuck, MD