H&P Data Perioperative and Transitional Medicine Group, PLLC 8210 Walnut Hill Ln. Suite 312 Dallas, TX 75231 Phone: 214-238-3074 - Fax: 214-238-3608 - On call: 469-213-1045 Patient : ABCD sample DOB : 04/10/1974 Age/Sex : 49/Female Admit Date : Encounter Type : Primary Care Encounter Mode : Face to face Encounter Date : 06/05/2023 Phone : 986-108-2196 Location Autumn leaves Address : DDS Lab,5440 Beaumont Center Blvd Ste 400, FL, Tampa, 33634 PRIMARY INSURANCE : Insurance : MediNiranjTest Insurance Id: aaaii Group Number: qqqii HISTORY AND PHYSICAL Complexity Level : High Reason for visit : Examination and medical management of this patient that has multiple significant chronic medical issues, on multiple drugs, with significant potential side effects History of Present Illness : The patient's pain is: Description: Location: Association: Frequency: Duration: Made worse by: Relieved by: Cigarette or Alcohol : Cigarette smoking : Negative Use of alcohol of greater than two drinks per day : Negative IV drug abuse : Negative FAMILY HISTORY : DRUG ALLERGIES : Allergies dsdsdsdsd ROS : Review of Systems Present: Review of Systems Not present: Constitutional: Fever, chills, shakes, weight loss, fatigue. Eyes: change in vision, loss of vision, eye pain. HENT: impaired hearing, loose or painful teeth, pain swallowing. Respiratory: shortness of breath, cough, coughing blood, sputum. Cardiovascular: chest pain, PND, arrhythmia, cardiac murmur. Gastrointestinal: liver disease, indigestion, nausea, diarrhea, vomiting, vomiting blood, blood in BM, abdominal pain, constipation. Genitourinary: difficulty urinating, pain urinating, blood in urine. Musculoskeletal: abnormal gait, gout, assistance with mobility. Skin: Rash or lesion. Neurological: loss of sensation, loss of taste, loss of smell, loss of hearing, chronic headache, seizure.. Allergic: itching, runny nose, blocked nose, sneezing. Hematologic: unusual bruising or bleeding, relatives with a bleeding tendency. Post-op: History of post-operative confusion or complications with previous anesthesia. Physical Exam : Constitutional: AAOx3, in no acute distress. The patient has normal body habitus with no deformities. Eyes: Exam of the eyelids reveals no lesions. Conjunctivae are normal. The pupils are equally round and responsive to light. HENT: Exam of the head reveals it to be normocephalic without evidence of trauma. Exam of the ears and nose reveal a normal overall appearance, with no scars, lesions or masses present. Exam of the mouth reveals no lesions on the posterior pharynx, hard and soft palate or tongue. Dental exam shows no signs of dental decay. Exam of the lips and oral mucosa reveal normal hydration. Neck: Exam of the neck reveals it to be supple. There are no masses, nodes, or thyroid enlargement. Lungs: There is a normal respiratory rate and effort. Auscultation of the lungs reveals clear breath sounds bilaterally. Cardiac: Cardiovascular exam reveals regular rhythm and rate with no evidence of murmur. There is no S3 or S4. Exam of the carotid pulses reveal pulse amplitudes that are normal and symmetric. There are no carotid bruits. Exam of the abdominal aorta reveals no enlargement and no bruits. Exam of the radial pulses reveal pulse amplitudes that are normal and symmetric. Exam of the dorsalis pedis pulses reveal pulse amplitudes that are normal and symmetric. Exam of the posterior tibial pulses reveal pulse amplitudes that are normal and symmetric. Exam of the extremities reveals no edema. Abdomen: Bowel sound frequency is normal. Bowel sound pitch is normal. Palpation of the abdomen reveals it to be soft and non-tender. Examination of the liver and spleen reveals no evidence of enlargement. Skin: Inspection of the skin reveals no lesions. Inspection of the skin reveals no rashes. Lymphatic: Exam of the lymphatic system in the neck reveals no adenopathy. Exam of the lymphatic system in the axillary region reveals no adenopathy. Exam of the lymphatic system in the inguinal region reveals no adenopathy. Exam of the lymphatic system in the femoral region reveals no adenopathy. Psychiatric: No depression, anxiety nor agitation noted. Neurologic: Cranial nerves II through XII are intact. The patient is oriented to person, place and time. Foreign bodies: none LAB DATA : Recent sugars – n/a Hospital labs reviewed in detail : WBC Hgb PLT TSH Free T4 A1C BNP - - - - - - - Na K Cl CO2 Cr ALB Mg - - - - - - - ESTABLISHED PROBLEMS : sdssdsdsd NOTE: Each of the acute and chronic medical issues were independently evaluated and decisions regarding their therapies were made the time of service. CONSULTANTS REQUESTED : Dietician SEND REFERRAL : Specialty Type: Name: Phone: Address: Detox Clinic Dallas ADHC Detox Clinic 469-221-6000 7502 Greenville Ave, Dallas, Texas, United States, 75231 Provider Name Provider Signature Niranjana Nephro Test
