Name: John C.
MRN: 123456
DOB: 07/25/1965
Age: 47
CC: New Patient/Initial Wellness Visit
HPI: Mr. C is a 47 year old male with a history of HTN, hyperlipidemia, thoracic aortic aneurysm and
depression. He presents to the office as a new patient and for an initial wellness visit. Mr. C states he is
primarily concerned about his long term hypertension, which continues to be poorly controlled with his
current medication regimen. He states that when his blood pressure gets “really high” he “doesn’t feel
right” and develops a headache with dizziness, for which he has previously visited the ER at Jersey Shore
hospital twice and undergone rapid reduction of his hypertension. Mr. C does not have records of his ER
visits with him today and states that his last visit was “a couple of months ago”. Mr. C also states he has
an aortic aneurysm “in his chest” which has been previously monitored, but has not been reevaluated in
in the last two years.
Today, Mr. C states that he feels “fine” and denies having a headache or dizziness. Additionally Mr. C
denies experiencing any chest pain, SOB, palpitations, peripheral edema, nausea, vomiting, changes in
vision or coughing. Mr. C states that he has had high blood pressure for 3-4 years, which he attributes
to a diet that consists primarily of “nicotine and caffeine”. Other than continuing to experience some
insomnia and increased fatigue, he has no complaints. Mr. C denies experiencing any pain currently.
PMH:
Medications: Benicar 40mg PO Q daily
Lisinopril 10mg PO daily
Paroxetine 20mg PO Q daily
Atorvastatin 10mg PO QHS
Vitamins: None
Herbals: None
Allergies: Latex Sensitivity (rash)
Immunizations: Current
Surgical Procedures: None
Hospitalizations: No admissions, two visits to ER in last year secondary to hypertensive urgencies
Trauma: Fall from ladder (1992) with fracture to right ankle
Illnesses: HTN diagnosed “3-4 years ago”, patient states that it has never been well controlled,
despite medication. Diagnosed with depression 2 years ago, at which point he was started on
paroxetine. Mr. C states he continues to feel fatigued and have insomnia several days a week.
Started on atorvastatin approximately one year ago for hyperlipidemia. No records available for
evaluation of patient’s thoracic aortic aneurysm.
Family History:
Father: Died of “heart disease” at 72
Mother: Died of “heart disease” at 81
Brother: Alive and well, HTN, 44 years old
Son: Alive and well, 18 years old
Patient denies a family history of diabetes mellitus, cerebrovascular issues, bleeding disorders,
cancer and known history of aortic aneurysms.
Social History: Mr. C works at a local construction company in waste water treatment. He is married and
lives with his family locally. He smokes approximately 20 cigars daily and drinks 1-2 beers a month. He
also drinks on 4-6 caffeinated beverages daily. Denies use of illicit drugs. Mr. N does not exercise
regularly.
ROS:
General: Gets “lightheaded” when his blood pressure is high. Also feels fatigued most days,
despite getting 7 hours of sleep. Denies weight gain/loss in last year, loss of appetite, fatigue,
fever, chills, or night sweats
Skin: Denies rashes, pruritus, ecchymosis, lesions, or erythema
Head: Headaches occasionally, including prior to his trips to the ED. Denies history of trauma to
head, bumps or lesions
Eyes: Denied changes in vision, blurred vision, diplopia, itching or sensitivity to light; Wears
glasses, however last eye exam was approximately two years ago.
Ears: Denies changes in hearing, tinnitus, infections or vertigo
Nose: Denies changes or loss of sense of smell, rhinorrhea, congestion, or sinus infections
Throat: Denies bleeding of gums, dry mouth, lesions or ulcers in mouth
Neck: Denies pain or stiffness of neck; Denies history of thyroid issues or enlarged lymph nodes
Pulmonary: Denies cough, sputum production, shortness of breath, wheezing or hemoptysis
Cardiovascular: Denies chest pain, palpitations, angina, dyspnea on exertion, or claudication
GI: Denies dysphagia, reflux, decrease in appetite, nausea, vomiting, hematemesis, diarrhea,
constipation, hematochezia, or melena
Endocrine: Denies heat/cold intolerance, polyuria, polydipsia, or polyphagia
Neurological: Denies history of seizures, weakness, paralysis, numbness, previous CVA or
tingling
Genitourinary: Denies increased frequency, urgency, incontinence, dysuria, hematuria, or
history of UTIs
Musculoskeletal: Occasionally experiences low back pain. Denies current musculoskeletal/joint
pain, joint swelling, or arthritis
Hematology: Denies history of anemia, easy bruising or bleeding
Psychiatric: Diagnosed with depression in 2011, currently denies feeling depressed. Denies
history of anxiety, nervousness, illicit substance abuse or memory problems
Physical Exam:
General: Pleasant affect and cooperative throughout interview/exam; Appears to be in no acute
distress and is alert and orientated to person, place and time
Vital Signs: Temp: 98.1F (tympanic) Respirations: 20 HR: 72 BP: 180/110 (repeated with electric
cuff: 191/118) Height: 72 inches Weight: 108 kg BMI: 32.3
Skin: Warm, dry, pink. No cyanosis/clubbing of nails.
Nodes: No cervical, submandibular, supraclavicular, infraclavicular or axillary lymphadenopathy
Head: Normocephalic, non-tender; No masses, lacerations, or lesions
Eyes: PERRLA; Visual acuity: Right eye20/40 Left eye 20/25 without correction, 20/20 with
glasses; EOMI; Conjunctiva and sclera clear; No ptosis noted; No papilledema/AV nicking/cotton
wool spots; Cup-to-disc ratio 1:3
Ears: No hearing loss detected; tympanic membranes non-erythematous with equal mobility
Nose: Symmetrical with no lesions, obstruction, inflammation or exudate noted; Frontal,
maxillary and ethmoid sinuses non-tender
Throat: Gums erythematous, no active bleeding noted; Multiple caries noted; No lesions, ulcers,
or exudate of tongue or pharynx; Tonsils present and equal bilaterally; Moist mucous
membranes; No deviation of the tongue; No lesions, masses or loss of ROM; Uvula symmetrical
and non-erythematous
Neck: Supple; Trachea is midline; Non-tender; No masses, carotid bruits, JVD, lesions or edema
Chest/Lungs: Lungs clear to auscultation bilaterally; Non-labored breathing; Symmetrical chest
expansion; No wheezing/rales/rhonchi/stridor
Heart: Regular rate and rhythm; S1 and S2 appreciated; no murmurs/ rubs/thrills; No peripheral
edema
Abdomen: Obese; Soft, non-tender; No ecchymosis, striae, or bruits; Normoactive bowel sounds
x 4; No organomegaly
Rectal: Deferred by preceptor.
Would assess for: Equal and concentric rectal tone; Appropriate prostate size, with no
masses/tenderness
Musculoskeletal: No deformities/ecchymosis/edema. Capillary refill two seconds in upper and
lower extremities
Peripheral Vascular: Radial, Posterior Tibial and Dorsalis Pedis pulses present and equal
bilaterally, +2/4
Neurologic:
CN II: Visual acuity: Right eye 20/40 Left eye 20/25 without correction, 20/20 with
corrective glasses; Visual fields intact
CN III, IV, VI: EOMI; no ptosis or nystagmius noted
CN V: Facial sensation intact to light palpation; Masseter and temporalis muscles intact,
with full ROM
CN VII: Patient raises eyebrows equally, can close eyelids tightly, smile, and frown
CN IX, X: Palate moves midline and superiorly and patient able to swallow; Uvula
symmetrical and rises equally with swallowing
CN XI: Able to shrug shoulders and rotate neck against resistance
CN XII: Tongue movement is symmetrical with strength against resistance
Mental Status: Orientated to person, place and time; Appropriate affect and mood; No
dysarthria
Additional mental status exam deferred. Additional testing to be evaluated include: Abstract
reasoning via proverb; Able to read and write sentence; Awareness of current events, follows
simple commands; Long term memory tested by recollection of past presidents and news
events; Three object recall used to test short term memory
Assessment:
1)
2)
3)
4)
5)
6)
Uncontrolled Hypertension
Thoracic Aortic Aneurysm
Hyperlipidemia
Depression
Obesity
Tobacco Abuse
Additional Testing Ordered: CBC, CMP, TSH
Additional Studies Ordered: Chest CT with contrast for evaluation of aneurysm
Medication Changes: Discontinue Benicar and Paroxetine
Start Azor 10/40mg PO Q daily
Start Aspirin 81mg PO Q daily
Start Cymbalta 60mg PO Q daily
Plan:
Mr. C’s history of very poorly controlled hypertension is concerning and we discussed for 30
minutes with the patient various ways to improve his hypertension and overall health.
Discontinued patient’s Benicar and started on Azor 10/40mg. If he does not benefit from this
medication, would consider switching to Tribenzor in the future for additional control. Strongly
encouraged Mr. C to stop smoking, as it can contribute to his hypertension, progression of his
thoracic aortic aneurysm and increases his risk of cancer and COPD. At this point, Mr. C stated
that he would try to cut down on smoking.
Mr. C is scheduled for a chest CT for evaluation of his thoracic aortic aneurysm. Discussed the
warning signs he should be aware of concerning his aneurysm, including sharp, sudden chest
and/or back pain. Discussed with Mr. C the importance of improving his diet by eating more
fruits and vegetables and decreasing his consumption of caffeine products. Also encouraged
Mr. C to increase his daily exercise as this will help him control his obesity. He is also scheduled
for a CBC, BMP and TSH to establish his baseline bloodwork and evaluate his hyperlipidemia as
well as possible secondary causes of his hypertension.
Due to Mr. C’s increased fatigue and insomnia, his Paroxetine was discontinued and he was
switched to Cymbalta 60mg. He was advised to contact the office or seek immediate medical
attention if he experiences any adverse reactions to his changes in medications. These
symptoms could include facial/body swelling, difficulty breathing and skin rashes/hives. Mr. C is
scheduled for a follow up appointment in 2 weeks at which time the results of his bloodwork
and imaging studies should be available for review. Mr. C was amiable to this course of action
and denied any further questions.
Vanessa G. Wittstruck, PA-S
4/05/13
17:54