DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
HARRIS, EDMOND (id #2008, dob: 02/16/1942)
Patient
Name
HARRIS, EDMOND (74yo, M) ID#
2008
02/16/1942
DONALD W. ROBERTSON, DO
DOB
Provider
Insurance
Appt. Date/Time
09/22/2016 11:15AM
Service Dept.
Main Office
Med Primary: MEDICARE-FL (MEDICARE)
Insurance # : 291369457A
Med Secondary: AARP (MEDICARE SUPPLEMENT)
Insurance # : 03334882111
Prescription: ARGSDIR - Member is eligible.
Chief Complaint
Left abdominal pain, unexplained weight loss, cough
pt states he has a lump in his lower left abdominal pain. BM is very dense and watery
Patient's Care Team
Other: DONALD W ROBERTSON DO: 2828 S MCCALL RD STE 21, ENGLEWOOD, FL 34224, Ph (941) 474-8154, Fax (941)
473-3583 NPI: 1164405007
Patient's Pharmacies
WAL-MART PHARMACY 1874 (ERX): 2931 SOUTH MCCALL ROAD, ENGLEWOOD FL 34224, Ph (941) 475-8899, Fax
(941) 473-8949
Vitals
Pain Scale: 3 09/22/2016 12:40
Pulse: 100 bpm 09/22/2016
pm
T: 97.8 F° 09/22/2016
12:40 pm
Wt: 164 lbs 09/22/2016
12:39 pm
BMI: 24.9 09/22/2016
12:39 pm
Ht: 5 ft 8 in 09/22/2016
12:39 pm
12:39 pm
RR: 22 09/22/2016 12:40
pm
BP: 129/87 sitting L wrist
09/22/2016 12:40 pm
O2Sat: 98% Room Air at
Rest 09/22/2016
12:48 pm
Measurements
None recorded.
Allergies
Reviewed Allergies
PENICILLINS: - BUT CAN TAKE CEPHALOSPORINS
allery to PCN
Medications
Reviewed Medications
Asprin Ec Low Dose 81 mg tablet,delayed release
Take 1 tablet(s) every day by oral route.
09/08/16 entered
Bactrim DS 800 mg-160 mg tablet
Take 1 tablet(s) every 12 hours by oral route.
09/22/16 prescribed
carvedilol 25 mg tablet
Take 1 tablet(s) twice a day by oral route.
09/15/16 prescribed
Ceftin 500 mg tablet
Take 1 tablet(s) every 12 hours by oral route.
09/22/16 prescribed
cefTRIAXone 1 gram solution for injection
Take 1 g by injection route.
09/08/16 administered
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
HARRIS, EDMOND (id #2008, dob: 02/16/1942)
clonazePAM 1 mg tablet
Take 1 tablet(s) twice a day by oral route.
09/15/16 prescribed
clopidogrel 75 mg tablet
Take 1 tablet(s) every day by oral route.
09/08/16 entered
ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL nebulization soln
Inhale 3 mL 4 times a day by nebulization route.
09/22/16 prescribed
metroNIDAZOLE 500 mg tablet
Take 1 tablet(s) every 8 hours by oral route.
09/22/16 prescribed
NIFEdipine ER 30 mg tablet,extended release
Take 1 tablet(s) twice a day by oral route.
09/15/16 prescribed
ondansetron 4 mg disintegrating tablet
Take 1 tablet(s) 4 times a day by oral route.
09/08/16 prescribed
pantoprazole 40 mg tablet,delayed release
Take 1 tablet(s) every day by oral route.
09/15/16 prescribed
promethazine 25 mg tablet
Take 1 tablet(s) every 4 hours by oral route.
09/08/16 prescribed
raNITIdine 300 mg tablet
Take 1 tablet(s) every day by oral route.
09/08/16 entered
simvastatin 40 mg tablet
Take 1 tablet(s) every day by oral route.
09/15/16 prescribed
tamsulosin 0.4 mg capsule
Take 1 capsule(s) every day by oral route.
09/15/16 prescribed
Zantac 150 mg tablet
Take 1 tablet(s) twice a day by oral route.
09/15/16 prescribed
klor-cov, m20, magnesium, b12 500 mcq, D3 1000 IU, Co Q 10,
Vaccines
Reviewed Vaccines
Vaccine Type
Date
Amt.
Route
Site
Lot #
Mfr.
1413101
Novartis Pharmaceutical
Corporation
Influenza
influenza, seasonal, injectable
09/24/14
influenza, seasonal, injectable
10/05/13
novel Influenza-H1N1-09, all
formulations
01/21/10
Intramuscular
Problems
Reviewed Problems
Acute sinusitis - Onset: 09/19/2016
Generalized anxiety disorder - Onset: 09/15/2016
Chronic hypokalemia - Onset: 09/15/2016
Large bowel obstruction - Onset: 09/15/2016 - 9/16
Mixed hyperlipidemia - Onset: 09/08/2016
Benign prostatic hyperplasia - Onset: 09/08/2016
Gastritis - Onset: 09/08/2016
Essential hypertension - Onset: 09/08/2016
Exp.
Date
Date
on
VIS
VIS
Given
Vaccinator
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
HARRIS, EDMOND (id #2008, dob: 02/16/1942)
Diverticulitis - Onset: 09/08/2016 - WITH 2 COLON RESECTIONS
Coronary arteriosclerosis - Onset: 09/08/2016 - with 5 stents and CABG
Family History
Reviewed Family History
Father
- No current problems or disability
Mother
- No current problems or disability
Social History
Social History not reviewed (last reviewed 09/15/2016)
Smoking Status: Never smoker
Surgical History
Surgical History not reviewed (last reviewed 09/15/2016)
Past Medical History
Past Medical History not reviewed (last reviewed 09/15/2016)
HPI
ED HAS NOT BEEN EATING HIS STOOLS ARE LIKE PUDDING SEE PREVIOUS NOTES HE IS HAVING PAIN IN THE LLQ
AGAIN
ROS
Patient reports sore throat but reports no bleeding gums, no snoring, no dry mouth, no mouth ulcers, and no teeth problems.
He reports cough but reports no wheezing, no shortness of breath, no coughing up blood, and no sleep apnea. He reports no
abdominal pain, no nausea, no vomiting, no constipation, normal appetite, no diarrhea, not vomiting blood, no dyspepsia, and
no GERD; ABDOMINAL PAIN LLQ STOOL IS LIKE PUDDING ANOREXIA. He reports fatigue; VERY. He reports no fever,
no night sweats, no significant weight gain, no significant weight loss, and no exercise intolerance. He reports no dry eyes, no
vision change, and no irritation. He reports no difficulty hearing and no ear pain. He reports no frequent nosebleeds, no nose
problems, and no sinus problems. He reports no chest pain, no arm pain on exertion, no shortness of breath when walking, no
shortness of breath when lying down, no palpitations, and no known heart murmur. He reports no incontinence, no difficulty
urinating, no hematuria, and no increased frequency. He reports no muscle aches, no muscle weakness, no arthralgias/joint
pain, no back pain, and no swelling in the extremities. He reports no abnormal mole, no jaundice, no rashes, and no
laceration. He reports no loss of consciousness, no weakness, no numbness, no seizures, no dizziness, no migraines, no
headaches, and no tremor. He reports no depression, no sleep disturbances, feeling safe in a relationship, no alcohol abuse,
no anxiety, no hallucinations, and no suicidal thoughts. He reports no swollen glands, no bruising, and no excessive bleeding.
He reports no runny nose, no sinus pressure, no itching, no hives, and no frequent sneezing.
Physical Exam
Patient is a 74-year-old male.
Chaperone: Chaperone: present.
Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: mild distress.
Ambulation: ambulating normally.
Psychiatric: Insight: good judgement. Mental Status: normal mood and affect and active and alert. Orientation: to time, place,
and person. Memory: recent memory normal and remote memory normal.
Head: Head: normocephalic and atraumatic.
ENMT: Ears: no lesions on external ear, EACs clear, TMs clear, and TM mobility normal. Hearing: no hearing loss and Rinne
AC>BC. Nose: no lesions on external nose, septal deviation, sinus tenderness, or nasal discharge and nares patent and nasal
passages clear. Lips, Teeth, and Gums: no mouth or lip ulcers or bleeding gums and normal dentition. Oropharynx: no
erythema or exudates and moist mucous membranes and tonsils not enlarged; LEFT MAXILLARY SINUS DOES
ILLUMINATE PERSISTENT SOUNDS NASAL.
Neck: Neck: supple, FROM, trachea midline, and no masses. Lymph Nodes: no cervical LAD, supraclavicular LAD, axillary
LAD, or inguinal LAD. Thyroid: no enlargement or nodules and non-tender.
Lungs: Respiratory effort: no dyspnea. Percussion: no dullness, flatness, or hyperresonance. Auscultation: no wheezing,
rales/crackles, or rhonchi and breath sounds normal and diminished air movement.
Cardiovascular: Apical Impulse: not displaced. Heart Auscultation: normal S1 and S2; no murmurs, rubs, or gallops; and
RRR. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout.
Abdomen: Bowel Sounds: normal. Inspection and Palpation: no guarding, masses, rebound tenderness, or CVA tenderness
and soft, non-distended, and LLQ tenderness; AND MILDLY FIRM. Liver: non-tender and no hepatomegaly. Spleen: nontender and no splenomegaly. Hernia: none palpable.
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
HARRIS, EDMOND (id #2008, dob: 02/16/1942)
Musculoskeletal:: Motor Strength and Tone: normal and hypotonicity; WEAK. Joints, Bones, and Muscles: no contractures,
malalignment, tenderness, or bony abnormalities and normal movement of all extremities. Extremities: no cyanosis, edema,
varicosities, or palpable cord.
Neurologic: Gait and Station: normal gait and station. Cranial Nerves: grossly intact. Sensation: grossly intact and
monofilament test intact. Reflexes: DTRs 2+ bilaterally throughout. Coordination and Cerebellum: finger-to-nose intact and no
tremor.
Skin: Inspection and palpation: no rash, lesions, ulcer, induration, nodules, jaundice, or abnormal nevi and good turgor. Nails:
normal.
Back: Thoracolumbar Appearance: normal curvature.
Assessment / Plan
1. Diverticulitis - CHECK HEMOCCULTS AND STOOL FOR C DIFF
K57.92: Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding
metronidazole 500 mg tablet - Take 1 tablet(s) every 8 hours by oral route. Qty: 30 tablet(s) Refills: 9 Pharmacy:
WAL-MART PHARMACY 1874
Bactrim DS 800 mg-160 mg tablet - Take 1 tablet(s) every 12 hours by oral route. Qty: 20 tablet(s) Refills: 2
Pharmacy: WAL-MART PHARMACY 1874
Patient Instructions
stop the cipro and replace with bactrim he could have the complication of diverticulitis and restart the ceftin as he still has
the sinusitis discussed bowel program and get a kub today with a call report
Discussion Notes
CALLED PATIENT THE KUB WAS NEGATIVE I FEEL HE HAS DIVERTICULITIS AT THE AREA OF THE
ANASTAMOSIS OR AN ABSCESS WE WILL SPEAK TO THE GASTROENTEROLOGIST AND HE WAS ADVISED TO
GO TO THE ER OVER THE WEEKEND INI
Return to Office
Donald W. Robertson, DO for ESTABLISHED PATIENT 30 at Main Office on 10/27/2016 at 10:30 AM
Encounter Sign-Off
Encounter signed-off by Donald W. Robertson, DO, 09/22/2016.
Encounter performed and documented by Donald W. Robertson, DO
Encounter reviewed & signed by Donald W. Robertson, DO on 09/22/2016 at 7:00pm
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
HARRIS, EDMOND (id #2008, dob: 02/16/1942)
Patient
Name
HARRIS, EDMOND (75yo, M) ID#
2008
02/16/1942
DONALD W. ROBERTSON, DO
DOB
Provider
Insurance
Appt. Date/Time
04/13/2017 01:45PM
Service Dept.
Main Office
Med Primary: MEDICARE-FL (MEDICARE)
Insurance # : 291369457A
Med Secondary: AARP (MEDICARE SUPPLEMENT)
Insurance # : 03334882111
Prescription: ARGSDIR - Member is eligible.
Chief Complaint
abdominal pain
intermittent pain rt side that started 3 days ago chronic cough since last August runny sinus
Patient's Care Team
Other: DONALD W ROBERTSON DO: 2828 S MCCALL RD STE 21, ENGLEWOOD, FL 34224, Ph (941) 474-8154, Fax (941)
473-3583 NPI: 1164405007
Patient's Pharmacies
WAL-MART PHARMACY 1874 (ERX): 2931 SOUTH MCCALL ROAD, ENGLEWOOD FL 34224, Ph (941) 475-8899, Fax
(941) 473-8949
Vitals
Pain Scale: 5 04/13/2017 02:02
Pulse: 65 bpm regular
pm
T: 98.1 F° oral
04/13/2017 02:02 pm
Wt: 156 lbs 04/13/2017
04/13/2017 02:01 pm
BMI: 23.7 04/13/2017
02:01 pm
02:01 pm
RR: 20 04/13/2017 02:01
pm
BP: 116/71 sitting R arm
04/13/2017 02:02 pm
Ht: 5 ft 8 in 04/13/2017
02:00 pm
Measurements
None recorded.
Allergies
Reviewed Allergies
PENICILLINS: - BUT CAN TAKE CEPHALOSPORINS
allery to PCN
Medications
Reviewed Medications
ALPRAZolam 1 mg tablet
Take 1 tablet(s) twice a day by oral route as needed.
04/13/17 prescribed
carvedilol 12.5 mg tablet
Take 1 tablet(s) twice a day by oral route.
01/03/17 entered
Cipro 500 mg tablet
Take 1 tablet(s) every 12 hours by oral route.
04/13/17 prescribed
clonazePAM 1 mg tablet
Take 1 tablet(s) twice a day by oral route.
Internal Note: now once daily at bedtime
02/16/17 prescribed
clopidogrel 75 mg tablet
Take 1 tablet(s) every day by oral route.
04/13/17 prescribed
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
HARRIS, EDMOND (id #2008, dob: 02/16/1942)
metroNIDAZOLE 500 mg tablet
Take 1 tablet(s) every 8 hours by oral route.
04/13/17 prescribed
omeprazole 20 mg capsule,delayed release
Take 1 capsule(s) every day by oral route.
12/01/16 prescribed
PARoxetine 10 mg tablet
Take 1 tablet(s) every day by oral route.
12/12/16 prescribed
potassium chloride ER 20 mEq tablet,extended release
Take 1 tablet(s) every day by oral route.
01/03/17 entered
raNITIdine 150 mg tablet
Take 2 tablet(s) twice a day by oral route.
02/16/17 prescribed
simvastatin 20 mg tablet
Take 1 tablet(s) every day by oral route.
01/03/17 entered
tamsulosin 0.4 mg capsule
Take 1 capsule(s) every day by oral route.
Internal Note: HELD
04/13/17 prescribed
citracel, MVI w/ iron, magnesium
Vaccines
Vaccines not reviewed (last reviewed 01/03/2017)
Vaccine Type
Date
Amt.
Route
Site
Lot #
Mfr.
1413101
Novartis Pharmaceutical
Corporation
Exp.
Date
Date
on
VIS
VIS
Given
Vaccinator
Influenza
influenza, seasonal, injectable
09/24/14
influenza, seasonal, injectable
10/05/13
novel Influenza-H1N1-09, all
formulations
01/21/10
Intramuscular
Some vaccines listed in Documents: #45545, #46572, #47504, #50533, #60869, #76533 could not be added to this patient's
chart. Please review these documents and add these vaccines to the patient's chart manually as needed.
Problems
Reviewed Problems
History of cholecystectomy - Onset: 04/13/2017
Anemia - Onset: 02/16/2017
Acute sinusitis - Onset: 09/19/2016
Generalized anxiety disorder - Onset: 09/15/2016
Depressive disorder - Onset: 12/12/2016
Chronic hypokalemia - Onset: 09/15/2016
Large bowel obstruction - Onset: 09/15/2016 - 9/16 WITH A RESECTION
Mixed hyperlipidemia - Onset: 09/08/2016
Benign prostatic hyperplasia - Onset: 09/08/2016
Gastritis - Onset: 09/08/2016
Essential hypertension - Onset: 09/08/2016
Diverticulitis - Onset: 09/08/2016 - WITH 2 COLON RESECTIONS
Coronary arteriosclerosis - Onset: 09/08/2016 - with 5 stents and CABG
Family History
Family History not reviewed (last reviewed 09/30/2016)
Father
- No current problems or disability
Mother
- No current problems or disability
Social History
Social History not reviewed (last reviewed 09/30/2016)
Smoking Status: Never smoker
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
HARRIS, EDMOND (id #2008, dob: 02/16/1942)
Surgical History
Surgical History not reviewed (last reviewed 09/30/2016)
Past Medical History
Past Medical History not reviewed (last reviewed 09/30/2016)
HPI
BROUGHT IN MEDS AND WE REVIEWED NOTS AND LABS STILL HAS A COUGH SWALLOWING IS BETTER HE HAD A
CARDICC CATHETERIZATION AND AN ANGIOPLASTY 3/31/17 NOW HE HAS PAIN IN THE RUQ SINCE THEN AND HE
CAN FEEL A KNOW NOT RELATED TO MEALS MAYBE RE;LATED TO MOVEMENT NO NAUSEA 3 DAYS OF PAIN HE
HAS HAD THE GALLBLADDER OUT
ROS
Patient reports difficulty hearing and ear pain; RIGHT. He reports cough but reports no shortness of breath; CHRONIC. He
reports anxiety but reports no depression, no sleep disturbances, feeling safe in a relationship, no alcohol abuse, no
hallucinations, and no suicidal thoughts. He reports no fever. He reports no dry eyes, no vision change, and no irritation. He
reports no frequent nosebleeds, no nose problems, and no sinus problems. He reports no sore throat, no bleeding gums, no
snoring, no dry mouth, no mouth ulcers, no oral abnormalities, and no teeth problems. He reports no chest pain, no arm pain
on exertion, no shortness of breath when walking, and no palpitations. He reports no abdominal pain, no nausea, and no
vomiting. He reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. He reports no muscle
aches and no muscle weakness. He reports no abnormal mole, no jaundice, no rashes, and no laceration. He reports no loss
of consciousness, no weakness, no numbness, no seizures, no dizziness, no migraines, no headaches, and no tremor. He
reports no fatigue. He reports no swollen glands, no bruising, and no excessive bleeding.
Additionally reports: NO HEARTBURN PAin does not wake him at night RADIATES AROUND TO THE BACK NO
URINARY SYMPTOMS THE RIGHT EAR FELS FULL HE IS NOT CONSTIPATED
Physical Exam
Patient is a 75-year-old male.
Chaperone: Chaperone: present.
Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: NAD; PALE.
Ambulation: ambulating normally.
Psychiatric: Insight: good judgement. Mental Status: active and alert; BETTER. Orientation: to time, place, and person.
Memory: recent memory normal and remote memory normal; BETTER.
Head: Head: normocephalic and atraumatic.
ENMT: Ears: no lesions on external ear, EACs clear, TMs clear, andTM immobile; RETRACTED RIGHT AND HE HAS A
MYRINGOTOMY TUBE ON THE LEFT. Hearing: no hearing loss and Rinne AC>BC. Nose: no lesions on external nose,
septal deviation, sinus tenderness, or nasal discharge and nares patent and nasal passages clear. Lips, Teeth, and Gums: no
mouth or lip ulcers or bleeding gums and normal dentition. Oropharynx: no erythema or exudates and moist mucous
membranes and tonsils not enlarged.
Neck: Neck: supple, FROM, trachea midline, and no masses. Lymph Nodes: no cervical LAD, supraclavicular LAD, axillary
LAD, or inguinal LAD. Thyroid: no enlargement or nodules and non-tender.
Lungs: Respiratory effort: no dyspnea. Percussion: no dullness, flatness, or hyperresonance. Auscultation: no wheezing or
rhonchi and breath sounds normal, good air movement, and dry rales/crackles; MILD.
Cardiovascular: Apical Impulse: not displaced. Heart Auscultation: normal S1 and S2; no murmurs, rubs, or gallops; and
RRR. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout.
Abdomen: Bowel Sounds: normal. Inspection and Palpation: no guarding, masses, rebound tenderness, or CVA tenderness
and soft and non-distended; THE COLON IS TENDER AND SLIGHTLY SWOLLEN AND PALPABLE IN THE RIGHT MID
LATERAL ABDOMEN AND I FEEL HE HAS SOME EARLY INFLAMMATION OR DIVERTICULITIS. Liver: non-tender and no
hepatomegaly. Spleen: non-tender and no splenomegaly. Hernia: none palpable.
Musculoskeletal:: Motor Strength and Tone: normal. Joints, Bones, and Muscles: no contractures, malalignment, tenderness,
or bony abnormalities and normal movement of all extremities. Extremities: no cyanosis, edema, varicosities, or palpable cord.
Neurologic: Gait and Station: normal gait and station. Cranial Nerves: grossly intact. Sensation: grossly intact and
monofilament test intact. Reflexes: DTRs 2+ bilaterally throughout. Coordination and Cerebellum: finger-to-nose intact and no
tremor.
Skin: Inspection and palpation: no rash, lesions, ulcer, induration, nodules, jaundice, or abnormal nevi and good turgor. Nails:
normal.
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
HARRIS, EDMOND (id #2008, dob: 02/16/1942)
Back: Thoracolumbar Appearance: normal curvature.
Assessment / Plan
1. Diverticulitis - CHECK HEMOCCULTS AND STOOL FOR C DIFF
K57.92: Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding
DIVERTICULITIS: CARE INSTRUCTIONS
LEARNING ABOUT DIVERTICULOSIS AND DIVERTICULITIS
metronidazole 500 mg tablet - Take 1 tablet(s) every 8 hours by oral route. Qty: 30 tablet(s) Refills: 9 Pharmacy:
WAL-MART PHARMACY 1874
Cipro 500 mg tablet - Take 1 tablet(s) every 12 hours by oral route. Qty: 20 tablet(s) Refills: 2 Pharmacy: WALMART PHARMACY 1874
2. Chronic hypokalemia
E87.6: Hypokalemia
3. Essential hypertension
I10: Essential (primary) hypertension
HIGH BLOOD PRESSURE: CARE INSTRUCTIONS
LEARNING ABOUT HIGH BLOOD PRESSURE
4. Coronary arteriosclerosis
I25.10: Atherosclerotic heart disease of native coronary artery without angina pectoris
clopidogrel 75 mg tablet - Take 1 tablet(s) every day by oral route. Qty: 90 tablet(s)
MART PHARMACY 1874
Refills: 9
Pharmacy: WAL-
5. Serous otitis media - Right
H65.91: Unspecified nonsuppurative otitis media, right ear
6. Benign prostatic hyperplasia
N40.0: Benign prostatic hyperplasia without lower urinary tract symptoms
BENIGN PROSTATIC HYPERPLASIA: CARE INSTRUCTIONS
tamsulosin 0.4 mg capsule - Take 1 capsule(s) every day by oral route. Qty: 90 capsule(s)
WAL-MART PHARMACY 1874
7. Generalized anxiety disorder - CLONAZEPAM DOES NOT WORK
F41.1: Generalized anxiety disorder
ANXIETY DISORDER: CARE INSTRUCTIONS
alprazolam 1 mg tablet - Take 1 tablet(s) twice a day by oral route as needed.
Pharmacy: WAL-MART PHARMACY 1874
Refills: 9
Qty: 60 tablet(s)
Refills: 2
Patient Goals
CBC CMP RTO NEXT WEEK
Return to Office
Donald W. Robertson, DO for ESTABLISHED PATIENT 30 at Main Office on 04/18/2017 at 02:30 PM
Encounter Sign-Off
Encounter signed-off by Donald W. Robertson, DO, 04/13/2017.
Encounter performed and documented by Donald W. Robertson, DO
Encounter reviewed & signed by Donald W. Robertson, DO on 04/13/2017 at 2:33pm
Pharmacy:
Name:
Pt. Encounter Number:
Date:
Age:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
Sex:
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other
related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Family History
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, TB
Eyes
Corrective lenses, blurring, visual changes of any
kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, black tarry
stools
Ears
Ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDS
Fe: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, osteoporosis
Breast
SBE, lumps, bumps or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, black out spells
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, previous dx
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, cold or heat intolerance
OBJECTIVE
Weight
BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first, then brighter later.
Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.
A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink
and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is
smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis – pending
Urine culture – pending
Wet prep - pending
Special Tests
Diagnosis
Include at least 3 differential diagnosis
Final Diagnosis
▪ Evidence for final diagnosis should be documented in your Subjective and
Objective exam.
PLAN including Education
o Plan:
▪ Further testing
▪ Medication
▪ Education
▪ Non-medication treatments
▪ Follow up
o
o
The following outlines what should be included in the extended SOAP note:
I. SOAP Evaluation
1. Sign and symptoms/Clinical presentation of disease process
a. How did your patient present: include history
2. Diagnostic workup: both typical and what was done with your patient
a. Physical findings
b. Testing
c. Imaging studies
3. Differential Diagnosis
a. Minimum of 3
b. How did you rule in/rule out the diagnosis
4. Final Diagnosis
a. What factors from your history and physical led to this diagnosis
5. Management
a. Pharmacologic
b. Non-pharmacologic
6. Education
II. Disease Background
1. Anatomy
2. Etiology
a. Risk factors
3. Pathophysiology
a. Consequences: adult and Geriatric
4. Epidemiology
a. Cultural, age, race, gender, US, International
5. Prognosis
6. Patient Education
III. Treatment Evaluation
1. Approach considerations
a. Guidelines and literature referenced
2. Complications
3. Health promotion and risk reduction
4. Medicolegal Concerns
5. Future Research needed
6. Consultation
7. Long term monitoring
8. Ethical and cultural consideration
9. Cost
IV. Critical Reflection of interaction and investigation.
V. Minimum of five test questions based on objectives and presentation.
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