Sample Note of a Complex New patient

AIM Initial Visit     Name: XXXX. MRN 12345678 Home phone 555-5555

CC: 68 year old male, referred by rheumatologist for primary care, and work up of abdominal pain.

PmHx (for patient with complex hx, it is better to break down each diagnosis and provide a description of past and present pertinents for each)

  1. End Stage Severe RA, with destruction of multiple joints. S/P 26 orthopedic surgeries in the past, he is wheel chair bound at baseline due to total destruction of both feet, knees and hips. RA is felt to be "burned out" x yrs, and he hass not taken any immunosuppressants for many years
  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

HPI: patient complains of epigastric pain 2-3 times/week. Pain is rated 6/10 radiates to the back, but not to the arms or throat. It last minutes to ½ hr. Pain is described to be pre-prandial, and worse with hunger. Food helps sometimes, pain is not positional. He is taking celebrex 200 bid for RA pain, he has not been on prednisone x yrs. There is no melena or BRBPR, dysphagia, weight loss, or decreased appetite. He does not drink alcohol. BM are regular, with no hx of PUD.

ROS: (ROS should always be included, for documentation purpose, make sure sectioneparated from HPI and is titled ROS.) wheelchair bound x 10yrs, but able to walk a few steps If needed, has 8 hr home care, weight has been stable. There is no fever, chills, night sweats, chest pain, he is SOB with minimal exertion. No hx of syncope, neurologic deficits. Bowels are usually regular, there is no hx of hepatitis, pancreatitis. His vision is poor due to recently diagnosed bilateral cataracts. He denies depression or anxiety symptoms.

MEDs:

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 200 bid

 

Soc Hx: lives alone, has been on disability since 1969, has 12 hr home care with weekly VNS service.  Retired from clerical work with the City.  No known occupational exposures.  Denies ETOH, recreational drug use, cigarette use.  Receives SSI, feels that income is adequate to sustain his lifestyle.  Family is involved in care.

FmHx: not known. orphaned at young age

                                                                                          Children healthy

Psurg Hx: Partial lobectomy 1967, "too many to count" joint surgeries, hernia repair 1975

 

 

Exam: older than stated age, sitting in wheel chair, talkative, insightful, and pleasant

V.S. BP 160/90 HR 68 T98.0 R 20 Weight 200lbs with specialize motor wheelchair

HEENT: bilateral opacity of lenses, unable to see disc, EOMI, PERRL, oral pharynx clear and moist

Neck: no JVD, no thyromegaly, extreme neck movement not attempted, but neck seems supple

Cor: RRR S1, S2, loud III/IV cres/decresc systolic m LUSB radiates to neck, carotid pulses bounding

Lungs: crackles and diminished breath sounds at bases

Abd: scaphoid, +BS, soft, no organomegaly, NT to palp, no bruits

Back some kyphosis, NT

Extrem: diffuse joint destruction, both feet deformed and contracted, all digits in hands contracted and has loss of bone, no pedal edema

Neurologic: nl CN, strength grossly nl proximally, MS intact Rectal: stool guaiac negative, prostate 3+

 

Data:……..Lab….. CXR…….Echo……..(a detailed explanation of pertinent past labs, and most current labs and studies should be included here)

 

Formulation: Complicated 68 y.o. M with multiple advance conditions, most notably end stage RA, critical AS, severe COPD. Recently with new onset epigastric abdominal pain, worse before meals. Exam with baseline findings, heme negative stool.

 

Impression/Plan

1.      Abdominal Pain (always address your patient’s primary concern by making the chief complaint problem #1): some features suggestive of PUD, no signs of GI bleed. On chronic NSAID and ASA, very much at risk. Would go ahead and give a diagnostic and possibly therapeutic trial of H2 blocker, would like to plan for EGD soon if health status permits. Would check CBC and ferritin to assess for occult bleed.

2.      Critical AS: poor functional status, would not tolerate surgery well, currently plans for medical management on ACE, on stable diuretics. To follow with cardiology. Would need Abx for any dental work.

3.      RA: "burned out" joints, NSAID controls pain, but left with a lot of joint destruction. Especially concerning is the C1 compression. This is important if he goes for any surgeries, or undergoes any procedure needing intubation. Will follow his headache patterns and follow him for new neuro deficits. May benefit from a neurologic consultation to assess the stability of the cervical process.

4.      CRI: lytes and fluid status stable, cr stable, continue ACE, K stable. Follow urine protein.

5.      HTN: 1st visit with me, elevated, would repeat in 1month. Given reactive airway not a great candidate for beta blocker, would speak to cardiologist prior to instituting new agents.

6.      BPH: flomax seems to work for now, continue, no signs of urine retention.

7.      COPD: on combivent, no prior COPD exacerbation. If worsen may consider inhaled steroids for maximal COPD coverage, it will be hard to differentiate in him, whether his SOB is cardiovascular or pulmonary. He has had pneuvx and flu shot this year.

8.      Health Maintenance: difficult to apply usual screening measure to such an ill patient. He is up to date with vaccinations, had dental and ophtho care, his last colonoscopy was nl 5 yrs ago. Cholesterol is nl. The NY state proxy information is reviewed with him. Defer nutrition, safety counseling to next visit.

9.      Patient should return to me in 1 month, check labs 1 week before, trial of ranitidine bid given. Please provide FOBT cards. The general requisition should be filled out for the FOBT, a prescription of ranitidine will be given to the patient, a lab sheet should be filled. All should be pinned together with the billing sheet and placed in the discharge box.