Title: Patient Write up and Health Promotion Recommendations Instructions: your write up: you should have already conducted your interview and have a draft of the (subjective documentation), you will be writing up your physical exam (objective documentation), formulating your medical diagnosis (collaborative diagnosis)
Patient identification
Name: D. A
Age: 54
Race: White
Gender: Male
Subjective Data
Chief Complaint (CC):
Patient presented to the clinic today with complaints of heart palpitations
History of Present Illness (HIP)
Mr. Drew is a 56 years old male who presents at the Cape Cod clinic today with complaints of heart palpitations. The patient reports that the heart palpitations started about a week ago, and he first noticed the symptom while he was at the gym. He states that the palpitations come and go, and each episode last about 10-15 minutes. He states that the palpitations are about a 7/ 8 out of a 0-10 scale, when he has it. He denies having palpitations during clinic visit. He describes the palpitations as “it feels like my heart is going to come out of my body”. He denies taking any medications to alleviate symptoms; he states that the palpitation goes away on its own. He reports that the palpitations are aggravated by increased activity and anxiety.
Medications
Patient is under no medication
Allergies
Penicillin-Patient gets a rash as an allergic reaction to penicillin
Past Medical History
Patient has in the past experienced sudden sensations of spinning, which is triggered mainly when the patient is in motion. Patient claims having dizzy spells, where he feels as if the world around him is spinning.
Social History
Patient works full time as a Truck Driver. Denies ever smoking tobacco. Drinks on weekend’s socially, about 3-4 drinks. Denies use of illicit drugs. Patient attends to the gym 3- 4 times a week.
Family History:
Mother: Hypothyroid. Hypertension
Father: Hypertension. Hyperlipidemia
Sister: is healthy at 41-year-old age
Maternal Grandmother: Hypertension. Hypothyroid. Hyperlipidemia
Paternal Grandfather: Died at age of 88 years old with an MI
Review of Systems (ROS)
General: No abnormal changes in weight, fatigue, weakness, fever, chills, and night sweats.
Head: No history of trauma or headaches
Eye: No changes in vision. He denies use of corrective lenses
Ears- No hearing loss, tinnitus, vertigo, discharge, or earache
Nose/Sinuses: No rhinorrhea, stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure
Mouth/Throat/Neck: No bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth.
Respiratory: No shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis, Influenza.
Cardiovascular: No chest pain. Reports new episodes of palpitations. No edema. No murmurs. No ever having an abnormal EKG. No cardiac history.
Gastrointestinal: No abdominal discomfort, tenderness, distention, ascites. NO constipation, diarrhea, dark or bloody stools. No changes in diet regimen. No heartburns, nausea, vomiting. Feeling bloated, increased burping or gas. Denies liver, spleen, pancreas, or any other GI problems.
GE: No dysuria, frequency, burning or changes in urination. No strong odor in urine. No kidney problems, UTIs or bladder incontinence
Musculoskeletal: No muscle weakness, joint stiffness, gait changes, pain, joint instability, or swelling. No difficulties with range of motion. Denies numbness, tingling, or radiation. No previous musculoskeletal injuries or fractures.
Neurologic: No loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, seizures, change in mental status, or memory changes.
Skin: No skin changes, jaundice, cyanosis, rashes, moles, bruises, wounds, or any open areas
Objective Data
Vital Signs- Temperature- 98.6 orally. RR- 18. O2 saturation reading- 100% RA. Heart Rate- 98. BP- 130/69. Weight- 102 kg BMI 28
General survey- Patient is alert x3. Well groomed. Well nourished. Good posture. Pleasant. Answers all questions appropriately and maintains eye contact throughout interview. No acute distress
Skin, nails and hair- Skin is pink, dry, thin, and warm. No cyanosis and no jaundice. Fingernails are rounded, pink and firm. No clubbing. Toenails are pink, flat and pink. No clubbing. Skin turgor- no tenting. Hair/scalp- well distributed. No masses, no lesions