Additional Soap Notes

ROS Head : Normocephalic , atraumatic , hair evenly distributed. Eyes: Conjunctiva pink, sclera white, PERRLA, No redness and Edema Ears: No lesions, no edema. External ear canal clear. TMs, pearly gray, cone of light visible bilaterally. Nose: No redness or dryness. Nose is symmetric, turbinates pink and moist Mouth: Pink lips, no lesions. Poor dentition, Tongue is pink and moist, Uvula midline Neck: Trachea midline, no deviation. Carotid pulse present, 2+, no bruits Lymph nodes: No lymphadenopathy present Thorax and lungs: Lungs sounds clear throughout, breathing non-labored. AP diameter 2:1 Cardiovascular: regular rate and rhythm, S1 and S2 present, no murmurs or gallops Abdomen: Bowel sounds normoactive in all four quadrant, No tenderness, no masses or hernia Extremities: Warm pink and dry. No edema noted Peripheral Vascular: No edema. Less than 3 seconds of capillary refill Musculoskeletal: Symmetric deformity in the PIP, MCP and wrist joint noted. Limited flexion, extension. Tender and painful joints at DIP and MCP upon palpation. Muscle strength in bilateral extremities 3/5, gait unsteady Neurogenic: Mental Status: Alert, oriented to person, place and time. Recommendation /Plan: 1. Healthy diet and importance of exercise discussed 2. Continue lifestyle management with exercise dietary restriction and weight loss 3. Routine labs such as CBC, CMP and lipids ordered. Informed that he will be notified when results become available 4. Educated about use of sunscreen and safe driving 5. Immunization reviewed and updated 6. Depression screen completed 7. Return to the office in a year for annual wellness Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago. Reports that his blood sugar dropped too low which caused the accident. Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer. Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time. Reports that he had some indications of kidney damage when first diagnosed. His urine microalbumin today is 100. His last hemoglobin A1C drawn at the end of December is 11.9. Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7. His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker. Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today. Patient also has a history of gastroparesis and impotence. Patient requests Nexium and Viagra, neither of which are covered under the Health Plan. Situation: 32–year-old young women present to the office with swollen, painful and discolored hands Background: The patient had since January ongoing, swollen, painful and discolored hands. An ultrasound of the upper extremities was negative for DVT. She was seen by a rheumatologist because her C-reactive protein was elevated. Inflammatory arthritis was ruled out. Patient saw a vascular surgery who performed CT of the venous system of the upper extremities which was negative. Vascular surgery thought that her symptoms were likely due to ongoing vascular issue. Allergies: Metoprolol Medications: Cardiovascular: Aspirin 81mg tablet 1 tablet PO daily Gastrointestinal: Valcyclovir 1 gram tablet 2 tablets q 12 hours PO Assessment: Vitals: BP: 110/64 pulse 74, respiration 18, temperature 97.3 oral, SPO2sat: 99% RA , height 5’9, weight 202 lbs, BMI 29.8 *General: The patient is alert and oriented with daughter at her side. She is well -nourished. She does not appear to be in any respiratory distress. HEENT: Denies visual disturbances or changes. No ear pain or ear drainage. No nasal congestion.. Denies rhinorrhea. Denies history of deviated nasal septum, polyps or large adenoids. Denies epistaxis. Respiratory: Denies hemoptysis. No shortness of breath. Cardiovascular: No palpitations. Dizziness noted when standing. Integumentary: No rashes, no pruritis. No wounds or ulcers. Denies skin color changes. Gastrointestinal: Denies rectal bleeding or dark colored stools. Genitourinary: Patient currently menstruating, states that she has heavy flow. Skin: no jaundice, large pink scaly patch to the mid back Respiratory: No cough , no dyspnea or shortness of breath Cardiovascular: Normal S1 and S2, no murmur, no carotid bruits, Gastrointestinal: No nausea, vomiting, no diarrhea or bleeding Musculoskeletal : No joint pain , no back pain Neurologic: Memory intact, no motor or sensory loss, cranial nerves intact Impression: Anemia: differential diagnosis iron deficiency anemia, megaloblastic anemia Recommendation/Plan 1. Irondeficieny anemia significantly improved 2. Diet counseling and nutrition consultation 3. Consider consult with hematologist if hemoglobin is less than 9g/dL or HCT is less than or equal to 27% and doesn’t show any improvement with previously established treatment. 4. Follow-up in 4 weeks or call the office for any noticeable bleed or blood in stool