Sample of Complex Patient, follow up note

Date,  Clinic Follow up Visit

XXXXX telephone XXXXXX family emergency contact (informal proxy)XXXXXXX  tel XXXXXXX

68 y.o. M (a running problem list should be kept for all complex patient.  It will serve to make sure that you remember to address all of their active issues.)

  1. End Stage Severe RA, with destruction of multiple joints. S/P 26 orthopedic surgeries in the past, is wheel chair bound at baseline due to total destruction of both feet. RA is felt to be "burned out" x yrs, and he is not on any immunosuppressants
  2. IgA nephropathy with CRI, cr=2 at baseline, follows with renal
  3. Critical AS, severe MR, CHF class III-IV, not a candidate for surgical correction due to poor baseline health
  4. HTN chronic, poor control
  5. Hx of partial lobectomy in the work up of lung nodules, path c/w with rheumatic nodules
  6. COPD with severe obstruction on PFT
  7. Chronic headache attributed to RA, as cervical involvement is causing compession of C1 on the medulla
  8. BPH with a hx of urinary retention, had a failed/aborted TURP last year
  9. Recent onset of dyspepsia x 3 months, no danger signs, stool negative for blood, started on H2 blocker

Returns after one month of ranitidine trial, reports feeling much better. Only experience 1 bouts of dyspepsia in the past month. This occurred after eating chili at a family barbecue. Otherwise feels baseline. ROS no BRBPR, melena. Eating well. Joints feel baseline 2/10 pain, with good pain control with meds. Chronic exertional SOB continues with minimal exertion, sits in w/c all day.

MEDs:  (Updated Meds and allergies should be included on every note)

Flomax 0.8 daily                                                    Allergy: none

Lasix 80 bid                                                          

Catapress TTS . 3 q week                                                   Sochx: lives alone, 2 daughers in area, helpful, no

Cartia XT 180 BID                                                                defined proxy. Widowed x 30 yrs. Worked in

ECASA 325 daily                                                                                 past as clerk, stopped due to RA, went on SSI.

Vasotec 20 BID                                                                     No cig, etoh, drugs. No STD, not sexually active          

Combivent inhaler prn

Celebrex 100 bid prn

 

Exam: BP 145/85 P 72 T 97.8 R 14 (given that you have fully examined the patient 1 month before, you do not have to do a complete exam on this visit)

Neck no JVD

COR: RRR, S1, S2, systolic III/IV murmur not changed

Lungs: baseline decreased BS and dry crackles

Abd: soft nontender, no masses, bladder not enlarged

Extrem: no edema, chronic joint changes

 

Labs: CBC Hc 32 MC 70, Ferritin 4, FOBT 3/3 heme negative (review all the new data since last visit)

 

I/P: 68 y.o. multiple chronic medical conditions, now with dyspepsia improved with H2 blocker, however labs suggest iron deficiency anemia.

1.        GI: Labs show Fe def. anemia with recent dyspepsia. Resolution of abd pain is reassuring, but signs of occult bleed in the patient with several co-morbidities warrants further evaluations probably with EGD. Will consult GI.

2.        CV:stable will check with CARDs regarding the possibility of EGD.

3.        HTN better, follow for now.

4.        CRI creatinine stable

5.        RA: stable symptoms, consider changing to T #3 as we work up PUD.

6.        HM: up todate with vaccinations, patient forgot health proxy form, will bring in next visit. Counseling on nutrition, safety at home.

7.        RTC  in 6 weeks, after GI and cardiology consultation, Consult forms filled, M11Q renewal, Medicaid override forms filled.

 

HM awaiting proxy pnvx 04, flu 06, colonoscopy 05, ophtho 06, Td 97