S- Subjective Data:
68 y/o Caucausian female, married
History obtained from patient
Chief Complaint (CC): “I’m here for a routine follow-up on my diabetes and hypertension and to review
my labs. I also need refills on my medications. I’ve been keeping a log of my blood pressure and blood
sugars for you to see”.
History of Present Illness (HPI): Pt presents to clinic in order to receive results of lab work that was
performed one week ago in order to monitor her diabetes, hyperlipidemia, and Vitamin D level. Denies
any problems with blood sugars or blood pressure. States she has been keeping a log of both, checking
her blood pressure and blood sugar three times a day, since last visit in July 2014. Denies any factors in
her daily living that worsens blood sugars or blood pressure. States her blood sugars are generally higher
in the afternoons around 2 pm, but never over 250. States her blood pressure has been normal, ranging
between systolic of 110-125 and diastolic of 80-85.
Past Medical History:
Medications:
Flexeril 5 mg PO TID PRN back pain x 8 years
Hyzaar 100 mg/12.5 mg PO daily x 9 years for HTN
Norvasc 5 mg PO x 8 years for HTN
Plavix 75 mg PO daily x 5 years for Heart Disease
Protonix 40 mg PO daily x 4 years for GERD
Tradjenta 5 mg PO daily x 1 year for Diabetes Type II
Zocor 40 mg PO daily at bedtime x 3 years for Hyperlipidemia
Buspirone 10 mg PO daily x 5 years for Depression/Anxiety
Clonidine HCl 0.2 mg PO TID x 4 years for HTN
Estradiol 0.0375 mg/24hr transdermal patch- change weekly x 5 years for Menopause
Fenofibrate 160 mg PO daily at bedtime x 3 years for Hyperlipidemia
Losartan 100 mg/Hydrochlorothiazide 12.5 mg PO daily x 3 years for HTN and Heart Disease
Simvastatin 40 mg Po daily at bedtime x 3 years for Hyperlipidemia
One Touch Ultra Test strips- to check blood sugars TID
Albuterol nebulizers QID PRN wheezing/SOB x 7 years for COPD
Novolog Flexpen SQ TID (0700, 1100, 1600) x 3 years
>200- 0 units
201-250- 2 units
251-300- 4 units
301-350- 6 units
351- 400- 8 units
>400- 10 units
Patient denies problems/side effects with any of her medications. States she takes his medications as
prescribed on a daily basis.
Allergies: Crestor- since 2012, causes muscle weakness; Lipitor- since 2012, causes muscle weakness;
Morphine- since 2005, causes rash and itching
Prior Illnesses/Injuries:
Type II Diabetes Mellitus x 1 year; well controlled with medications
Hyperlipidemia x 9 years; well controlled with medications
Chronic Ischemic Heart Disease x 9 years; well controlled with medications
Hypertension x 8 years; well controlled with medications
Chronic Obstructive Pulmonary Disease x 7 years; well controlled with medications
Vitamin D Deficiency x 1 year; controlled with medications
Chronic Back Pain x 8 years; controlled with medications
Depression x 5 years; well controlled with medications
Anxiety x 5 years; well controlled with medications
GERD x 4 years; well controlled with medications
Chicken Pox as a child; denies any other major childhood illnesses
Previous Injuries: Patient reports a lower back injury in 1989. States she “hurt my back lifting pallets at
work”
Previous Operations:
Appendectomy- 1994; no complications
Cholecystectomy- 1994; no complications
Hysterectomy- 1996; no complications
Previous Hospitalizations: 2007- Bronchitis and diagnosis of COPD; 2011- COPD exacerbation; 2012COPD exacerbation
Flu vaccine: October 2013
Pneumococcal vaccine: October 2013
PPD Test- March 2014 normal
Family History:
Mother- deceased at age 70- Type II Diabetes Mellitus, Breast Cancer, CVA
Father- deceased at age 71- COPD, MI, Dementia
Brother- age 67- Hyperlipidemia, Type II Diabetes
Son- age 49- HTN, arthritis
Daughter- age 46- depression/anxiety, HTN
Daughter- age 40- seizures, scoliosis
Social History: Patient is married, one brother- age 67. Pt has one son, age 49, and two daughters, ages
46 and 40. Pt lives with her husband; two members of household. Patient and her husband are
disabled; lives on a fixed income of $2600 monthly. Patient denies any financial burdens. Patient has a
high school education. Pt is retired from Federal Mogul (worked on an assembly line x 25 years) in
Jacksonville, AL since 2009. Pt has an optimal support system from her family and church family. States
she spends a lot of her time caring for her daughter who has seizures and helping take care of her
daughters’ two boys, ages 14 and 9. Patient also spends a lot of her time taking care of her husband who
was diagnosed with lung cancer in 2012. Patient sees her primary care physician on a regular basis.
Denies use of alcohol. Patient has smoked cigarettes since she was 16; smokes 1 ppd. Denies past or
present use of recreational drugs. Patient states she and her husband walk for 30 minutes three times a
week.
Nutrition: Pt eats a lowered cholesterol diet. States she tries to avoid fried foods. Pt eats three meals
daily, once in the morning, once at lunch, and once in the evening. Patient states she eats two snacks
throughout the day, mainly consisting of peanut butter and crackers and fruit. Pt states she tries to drink
6 glasses of water daily.
Review of Symptoms:
1. Constitutional: Patient denies fatigue or weakness, recent weight loss or gain, denies fever.
2. Eyes: Patient denies vision changes, blurry vision, eye drainage/tearing, eye pain/itching or eye
redness. Denies photophobia. Patient wears glasses. Last eye exam- May 2014 with no abnormal
findings. Visual acuity at eye exam was 20/20 OU with corrective lenses. Denies difficulty driving at
night.
3. ENMT: Patient denies vertigo, hearing loss, tinnitus, or use of assistive hearing devices. Denies ear
pain, ear drainage. Denies nasal discharge or nosebleeds. Denies difficulty smelling. Pt denies
facial/sinus pain or sinus drainage. Patient wears upper and lower dentures that fit well. Denies pain
with dentures. Denis bleeding of gums, mouth odor, ulcers, or sores of the tongue.
Denies sore throat, hoarseness, or difficulty swallowing.
4. Cardiovascular: Patient denies chest pain, problems with blood pressure, palpitations, or peripheral
edema. Denies claudication or cyanosis of extremities. Denies leg redness or tenderness. Pt denies
history of heart murmur. Last visit with cardiologist, Dr. Sirna, one month ago. EKG and nuclear stress
test done one month ago with no abnormal findings. Last cardiac catheterization was in 2012 with no
abnormal findings.
5. Respiratory: Patient denies SOB at rest or upon exertion, orthopnea, or dyspnea. Denies wheezing,
hemoptysis, or night sweats. Last CXR- July 2014 with findings of flattening of diaphragm, consistent
with COPD. Pt denies cough. Pt states she usually has flare-ups of her COPD during the Spring and Fall,
but has not experienced any problems with it recently. Pt states she only has to use her Albuterol
nebulizer about twice a week, generally when she overexerts herself. Pt smokes 1 ppd of cigarettes x 52
years. States she is trying to cut back on her smoking.
6. Gastrointestinal: Patient denies any episodes of abdominal pain, nausea, vomiting, or diarrhea.
Reports regular, daily BM’s. Last normal BM was today. Denies blood in stool, rectal bleeding,
hemorrhoids, or constipation. Denies hematemesis. Denies heartburn. Reports normal appetite with
food intolerances to fried and spicy foods, which she tries to avoid.
7. Genitourinary: Patient denies dysuria, burning, urgency, hematuria, or frequency. Denies flank pain or
suprapubic pain. Denies recent urinary tract or bladder infections. Denies vaginal discharge, vaginal
itching, or history of STD. States she experiences stress incontinence, especially when she coughs or
sneezes. Not currently sexually active. Reports two lifetime sexual partners.
8. Musculoskeletal: Patient denies body aches, muscle pain, swelling, or stiffness. Denies recent injury
or trauma. Denies muscle cramps or muscle weakness. Reports she is physically active on a daily basis
and exercises three times a week. Denies neck pain or stiffness. Denies changes in range of motion of
upper and lower extremities. States she occasionally has lower back pain from an injury 8 years ago,
mainly when she overexerts herself. States she avoids lifting or pulling on heavy objects. Wears a back
brace during the day for support. Back brace if well fitted to patients body.
9. Skin: Patient denies skin lesions, rash, itching, moles, hair loss, or dryness. Reports sun exposure
approximately three times a week, but uses sunscreen when outdoors.
10. Neurologic: Patient denies headaches, dizziness, or vertigo. Denies syncopal episodes, fatigue, or
weakness. Denies muscle tremors, numbness, involuntary movements, or tingling. Denies sleep
disturbances.
11. Psychiatric: Patient denies decrease in memory or recent mood changes. Reports history of
depression and anxiety, but well controlled with medications. Denies hallucinations or paranoia. Denies
thoughts of harming self or others.
12. Endocrine: Type II Diabetes well controlled with diet and medications. Denies problems with her
thyroid. Patient denies intolerance to heat or cold, excessive sweating, thirst, or hunger. Denies any
unexplained changes in weight.
13. Hematologic/Lymphatic: Patient denies excessive bleeding, bruising, or history of anemia. Denies
any previous blood transfusions. Denies swollen lymph nodes or lymph node tenderness. Denies
previous history of blood clots.
15. Allergic/Immunologic: Denies seasonal allergies. Denies previous allergy testing. Denies hives,
rashes, or itchy, watery eyes. No exposure to blood or body fluids. Denies history of
immunosuppression, except when placed on Corticosteroid therapy for flare-ups of her COPD.
O- Objective Data:
1. Constitutional/General appearance: Patient appears in no acute distress, well developed, well
nourished. Appears stated age. Dressed appropriately and behaving in an appropriate manner. Alert and
oriented x 3.
Vital Signs: T- 98.0 oral, BP- 107/64 mm/Hg, HR-74 bpm, Respirations- 16/ minute, unlabored, Oxygen
sat- 98% on room air, Height- 67 inches, Weight- 182 lbs, BMI- 28.5.
Physical Examination:
2. Eyes: Sclera normal. No drainage or tearing noted from eyes, no redness. PERRLA. 4 mm bilaterally.
3. ENT/Mouth: Tympanic membranes normal, no bulging or redness noted, light reflex present. Hearing
intact to whispered voice. Nasal turbinates normal. No redness, paleness, or bogginess noted to nasal
mucosa. No nasal drainage noted, no deviated septum, no lesions noted. Maxillary and frontal sinuses
nontender upon light or deep palpation. Oral cavity mucosa pink and moist. Upper and lower dentures
noted and appears to be well-fitting. Pharynx reddened with no exudate visualized, tonsils present and
normal, uvula midline. No evidence of bleeding of gums or foul odor, no ulcers or sores.
Cardiovascular: Apical pulse normal. Regular rate and rhythm noted. Normal S1 and S2. No S3 or S4. No
murmurs, clicks, or gallops. Peripheral pulses with normal rate and rhythm. No JVD. No carotid bruits
auscultated. No edema noted to upper or lower extremities. Capillary refill brisk, < 3 seconds. No
discoloration noted to extremities. No varicose veins. AP diameter of chest is normal.
Respiratory: Equal rise and fall of chest visualized. No tenderness upon palpation. Patient with normal
rate and effort. Normal tactile fremitus. No hyperresonnance or dullness noted upon palpation.
Wheezing auscultated in upper lobes bilaterally; normal breath sounds auscultated in lower lobes
bilaterally. No rhonchi auscultated. Clubbing of fingers noted bilaterally.
Abdomen: Abdomen soft and nondistended. Bowel sounds normal in all four quadrants. No tenderness
noted upon light or deep palpation. No guarding.
Genitourinary: No CVA tenderness present.
Musculoskeletal: Normal ROM noted in upper and lower extremities. Pt reports lower back pain upon
bending forward, rates 3/10 and described as aching. Alleviated with standing upright. Patient denies
calf tenderness. Normal muscle strength in upper and lower extremities. No abnormal curvature of
spine.
Skin: Skin warm, dry, pink. No bruising noted. No discolored or uneven moles, open wounds, no redness
or rashes noted.
Neurological: Patient is alert and oriented x 3. Hand grips strong and equal bilaterally. Speech is clear.
No tremors or involuntary movements.
Psychiatric: Pt is calm, cooperative, behaving in an appropriate manner, answering questions
appropriately. Normal affect.
Hematologic/Lymphatic/Immunologic: No bruising noted. No enlarged lymph nodes palpated. Patient
denies tenderness upon palpation of thyroid.
Results of Diagnostic Tests:
Lipid panel, Basic Metabolic Profile, Vitamin D level, CBC, and HgbA1C collected one week prior to
current visit
CPT codes for labs:
Lipid panel- 80061
Basic Metabolic Profile- 80048
Vitamin D level- 82306
CBC w/ differential- 85026
HgbA1C- 83036
Drawing Fee- 36415
Abnormal labs:
Triglycerides- 165, elevated
LDL- 107, elevated
BUN- 30, elevated
Creatinine, serum- 1.62, elevated
EGFR- 37, low
Vitamin D- 26, low
CBC- normal
HgbA1C- 7, elevated
A- Assessment/Analysis:
Level of Visit: Level 4- Visit Code 99214
Diagnoses:
1. 250.00 Diabetes Type II Non-Insulin (Primary)
2. 268.9 Unspecified Vitamin D Deficiency
3. 272.4 Hyperlipidemia
4. 401.0 Malignant Essential Hypertension
5. 496 COPD, Chronic Airway Obstruction
6. 414.9 Unspecified Chronic Ischemic Heart Disease
7. 585.3 Chronic Kidney Disease, Stage III
P- Plan:
1. Continue Novolog Flex Pen per sliding scale and Tradjenta as prescribed.
1. Continue to check blood sugar TID and record in blood sugar log. Bring blood sugar log to next
scheduled visit.
2. New Rx for Cholecalciferol (Vitamin D3) 10,000 unit capsule, Take one capsule PO daily x one week,
then take one capsule PO twice weekly, dispense 40 with no refills, product selection permitted.
3. Refill on Simvastatin 40 mg PO, take one tablet PO at bedtime, dispense 90 tablets with no refills,
product selection permitted.
3. Continue low cholesterol, low salt, and heart healthy diet. Avoid fried foods. Bake, broil, or grill
foods, preferably chicken or fish. May have red meat or pork once a week.
4. Refill on Norvasc 5 mg PO, take one tablet PO BID, dispense 180 tablets with no refills, product
selection permitted.
4. Continue to keep blood pressure log.
5. Continue Albuterol nebulizer treatments QID PRN wheezing.
5. Stop smoking.
6. Refill on Plavix 75 mg PO, take one tablet PO daily, dispense 90 tablets with no refills, product
selection permitted.
7. Patient recently seen by nephrologist in August 2014. No medications at this time per nephrologist.
Patient is to have follow up labs drawn at nephrology clinic in two weeks to continue to monitor
kidney functions.
Follow-up- Patient is instructed to follow up in clinic in 3 months, sooner if needed.
Patient Education-
1. Patient is instructed to take all medications as prescribed and in their entirety. Medication
education provided for patient at time of discharge from clinic.
2. Counseling on benefits of exercise and cardiovascular fitness. Patient is encouraged to continue
exercising at least 30 minutes three times a week, 5 times a week if possible.
3. Smoking cessation education provided for patient.
Norvasc (Amlodipine Besylate)- prescribed for this patient for hypertension.
MOA- Inhibits calcium ion from entering the “slow channels” or select voltage-sensitive areas of
vascular smooth muscle and myocardium during depolarization; a peripheral arterial vasodilator that
causes a reduction in blood pressure.
Usual dosage- Initial dose of 5 mg PO once daily; maximum dose 10 mg PO daily; titrate in increments
of 2.5 mg over 7-14 days. Usual dosage range: 2.5 mg-10 mg PO daily.
Available as name brand, Norvasc. Also available as generic, Amlodipine Besylate.
Cost for 30 day supplyWal-Mart Jacksonville, Alabama: Brand: $35.49, Generic: $7.11
CVS, Jacksonville, Alabama: Brand: $47.55, Generic: $9.25
Walgreen’s, Jacksonville, Alabama: Brand: $55.99, Generic: $11.50