Consult - History and Phy.
Sample Name: Gen Med Consult - 33
Description: Patient with hypertension, dementia, and depression.
(Medical Transcription Sample Report)
MEDICAL PROBLEM LIST:
1. Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.
2. Dementia and depression.
4. History of atrial fibrillation. The patient has been in sinus rhythm as of late. The patient is not anticoagulated due to fall risk.
6. Degenerative arthritis of her spine.
9. Chronic rhinitis (the patient declines nasal steroids).
11. Chronic constipation.
12. Diabetes type II, 2006.
13. Painful bunions on feet bilaterally.
CURRENT MEDICINES: Aspirin 81 mg p.o. daily, Cymbalta 60 mg p.o. daily, Diovan 80 mg p.o. daily, felodipine 5 mg p.o. daily, omeprazole 20 mg daily, Toprol-XL 100 mg daily, Levoxyl 50 mcg daily, Lantus insulin 12 units subcutaneously h.s., simvastatin 10 mg p.o. daily, AyrGel to both nostrils twice daily, Senna S 2 tablets twice daily, Timoptic 1 drop both eyes twice daily, Tylenol 1000 mg 3 times daily, Xalatan 0.005% drops 1 drop both eyes at bedtime, and Tucks to rectum post BMs.
ALLERGIES: NO KNOWN DRUG ALLERGIES. ACE INHIBITOR MAY HAVE CAUSED A COUGH.
CODE STATUS: Do not resuscitate, healthcare proxy, palliative care orders in place.
DIET: No added salt, no concentrated sweets, thin liquids.
RESTRAINTS: None. The patient has declined use of chair check and bed check.
INTERVAL HISTORY: Overall, the patient has been doing reasonably well. She is being treated for some hemorrhoids, which are not painful for her. There has been a note that she is constipated.
Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188. I see a couple in the 150s. However, I also see one that is in the one teens and a couple in the 120s range.
She is not bothered by cough or rib pain. These are complaints, which I often hear about.
She is not having problems with breathing. No neurologic complaints or troubles. Pain is generally well managed just with Tylenol.
PHYSICAL EXAMINATION: Vitals: As in chart. The patient is pleasant and cooperative. She is in no apparent distress. Her lungs are clear to auscultation and percussion. Heart sounds regular to me. Abdomen: Soft. Extremities without any edema. At the rectum, she has a couple of large hemorrhoids, which are not thrombosed and are not tender.
ASSESSMENT AND PLAN:
1. Hypertension, good control, continue current.
2. Depression, well treated on Cymbalta. Continue.
3. Other issues seem to be doing pretty well. These include blood pressure, which is well controlled. We will continue the medicines. She is clinically euthyroid. We check that occasionally. Continue Tylenol.
4. For the bowels, I will increase the intensity of regimen there. I have a feeling she would not tolerate either the FiberCon tablets or Metamucil powder in a drink. I will try her on annulose and see how she does with that.
Keywords: consult - history and phy., cerebrovascular, atrial fibrillation, chronic rhinitis, depression, hypertension, hemorrhoids, progress,