67 year old white male seen in office 4/20/2017 case log number 4494203
Pt. is here for a problem with his eyes being red, itchy and some drainage since Sunday. He also needs to discuss his prescriptions because of insurance changes.
History of Present Illness
Patient complaints of itchy red eyes billaterally
Review of Systems
Constitutional: [No fevers, chills, sweats]
Eye: [No recent visual problems]
ENT: [No ear pain, nasal congestion, sore throat]
Respiratory: [No shortness of breath, cough]
Cardiovascular: [No Chest pain, palpitations, syncope]
Gastrointestinal: [No nausea, vomiting, diarrhea]
Genitourinary: [No hematuria]
Vitals & Measurements
HR: 68 (Peripheral) RR: 16 BP: 142/90 SpO2: 98%
General: [Alert and oriented, well nourished, no acute distress].
Eye: [PERRL, EOMI, red and itchy conjuctiva].
HENT: [Normocephalic, clear tympanic membranes, normal hearing, moist oral mucosa, no scleral icterus, no sinus tenderness].
Neck: [Supple, non-tender, no carotid bruits, no JVD,].
Lungs: [Clear to auscultation , non-labored respiration].
Heart: [Normal rate, regular rhythm,].
Abdomen: [Soft, non-tender, non-distended, normal bowel sounds, no masses].
Musculoskeletal: [Normal range of motion and strength, no tenderness or swelling].
Skin: [Skin is warm, dry and pink, no rashes or lesions].
Neurologic: [Awake, alert and oriented X4,].
Psychiatric: [Cooperative, appropriate mood and affect].
1. Viral eye infection H44.009
ciprofloxacin ophthalmic, 2 drop(s), OPTH, q4hr, X 7 day(s), # 5 mL, 0 Refill(s), 04/27/17, Pharmacy: Express Scripts Home Delivery, two drops bilateral bid, 2 drop(s) OPTH q4hr,x7 day(s)
Problem List/Past Medical History
Viral eye infection
No qualifying data
Anoro Ellipta 62.5 mcg-25 mcg/inh inhalation powder, 1 puff(s), INH, Daily, 2 refills
Aspirin Low Dose, Oral, Daily
ciprofloxacin 0.3% ophthalmic solution, 2 drop(s), OPTH, q4hr
Clarinex 5 mg oral tablet, 5 mg, 1 tab(s), Oral, Daily, 1 refills
Flomax 0.4 mg oral capsule, 0.8 mg, 2 cap(s), Oral, Daily
lisinopril 10 mg oral tablet, 10 mg, 1 tab(s), Oral, Daily
LORazepam 1 mg oral tablet, 1 mg, 1 tab(s), Oral, BID
montelukast 10 mg oral tablet, 10 mg, 1 tab(s), Oral, qPM, 1 refills
oxaprozin 600 mg oral tablet, 600 mg, 1 tab(s), Oral, BID, 1 refills
potassium chloride extended release, Oral
ProAir HFA 90 mcg/inh inhalation aerosol, 2 puff(s), INH, Once, PRN
simvastatin 10 mg oral tablet, 10 mg, 1 tab(s), Oral, Once a day (at bedtime), 1 refills
Alcohol - Denies Alcohol Use
Exercise - Regular exercise
Tobacco - Denies Tobacco Use
|Complete Subjective Information|
|PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.|
|Complete Objective Information|
|Complete physical exam with critical elements related to subjective data.|
|Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.|
|Create a Plan|
|Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.|
|Self Assessment & Clinical Guidelines|
|Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.|