Name:

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC: 

Reason given by the patient for seeking medical care “in quotes”. Select ONE complaint that you will investigate for this note. Do NOT select a routine follow-up exam, or a scheduled annual physical.

HPI: 

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications:
(list with reason for med )

PMH

Allergies:   

Medication Intolerances: 

Chronic Illnesses/Major traumas 

Hospitalizations/Surgeries 

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. 

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status

ROS

General

Weight change, fatigue, fever, chills, night sweats,  energy level 

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB 

Eyes

Corrective lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools 

Ears

Ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS

   Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

  Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight        BMI

Temp

BP

Height

Pulse

Resp

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Abdomen obese; BS in all 4 quadrants; you must designate whether the BS are normoactive, hyper, or hypo. Abdomen soft, non-tender. No hepatosplenomegaly. 

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable.

(Male:  both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis – pending

Urine culture – pending

Wet prep – pending

Special Tests

 Diagnosis

 Differential Diagnoses – List at least three possible diagnoses for the chief complaint. This is NOT a list of unrelated, multiple diagnoses the patient may have. Focus on the chief complaint.

You must include the rationales for why you are considering each differential as a possibility for this patient. Plan on two to three sentences for each differential diagnosis listed.

· 1-

· 2-

· 3-

Diagnosis – You must include how you arrived at this diagnosis. What was your thinking? You must convince me you are on the right path.

Plan/Therapeutics

· Plan:  Be specific to this patient and include the following as applicable.

· Further testing

· Medication

· Education

· Non-medication treatments

· Return to clinic

· Referrals

 Evaluation of patient encounter – The following are required components to this section of the note:

1. Self-Assessment: Answer each of the following questions:

—Was the plan of care evidence-based? How? Convince me why you are doing what you are doing.

—What did you learn? Be specific.

—Would you have changed anything in the encounter? Why or why not?

2. References to support your treatment plan – must be current and in the reference style as though you were writing a paper.

Name:

F.Z

Date: 14th Sept, 2020

Time: 1600hrs

Age: 68 years old

Sex: M

SUBJECTIVE

CC: Itchy skin lesions

HPI: An African-American male patient who present to the facility with itchy skin lesions that has been present for few months. According to him, he noticed the lesions on his knees and is now extending to his elbows and scalp. He reports that the lesions are slightly itchy and this has been the case for the last three weeks. She is stressful since the affected areas are now becoming painful. He has tried to change the bathing soap with no change and has been using ibuprofen 400mg three time a day for the relief of pain. According to her, the severity is 7/10.

Medications: OTC Ibuprofen 400 mg PO every 6 hours and Ortho Tri-cyclin 1 tablet PO daily

PMH

Allergies: NKDA

Medication Intolerances: No history of any medication intolerance

Chronic Illnesses/Major traumas: No history of the chronic or major traumas reported

Hospitalizations/Surgeries: No history of hospitalization for HTN, diabetes, asthma, peptic ulcers, lung illness, heart disease, Tuberculosis, kidney problem or the thyroid issues

Family History: Mother is alive and diagnosed with diabetes. Father dead with no known cause of the death. Maternal grandfather, dead, diagnosed with psoriasis

Social History: he is an undergraduate and a retired teacher. Like working in the farm. Reports no history of substance or alcohol use. Lives with the wife and three grandchildren. Stable and can perform his ADLs independently.

ROS

General: No reported chills or fever, no changes in the weight, report no night sweats, and denies fatigue.

Cardiovascular: Denies palpitations, pain of the chest, PND, orthopnea, and edema.

Skin: Delayed healing, bruises, discoloration of the skin, and presence of the moles and lesions

Respiratory: Denies coughing, wheezes, dyspnea, and history of pneumonia, tuberculosis, and hemoptysis.

Eyes: Denies the use of the corrective lenses, blurs, changes in the vision

Gastrointestinal: Denies abdominal pain, N/V/D, constipation, ulcers, black tarry stools, eating disorders, hepatitis, and the hemorrhoids.

Ears: Denies ear discharges, paining ear, hearing loss, and the ringing of the ear.

Genitourinary/Gynecological: Denies changes in the frequency, urgency, and the changes in the urine color. No urinary complaints

Nose/Mouth/Throat: denies sinus issues, dysphagia, bleeding or discharge of the nose, dental illness, hoarseness, and the pain of the throat.

Musculoskeletal: no history of the fracture, denies stiffness, back pain. Confirms pain and swelling of the knee and elbow.

Breast; Denies bumps, lumps and any changes

Neurological: Denies syncope, seizures, transient paralysis, paresthesia, and the spells of the black out. Confirms the weakness in the knee and elbow of the right hand.

Heme/Lymph/Endo: He is HIV negative, have bruises, no history of blood transfusion. Denies night sweats, increase in the hunger, heat or cold tolerance.

Psychiatric: Denies depression, suicidal thoughts, sleeping difficulties, and anxiety.

OBJECTIVE

Weight 63 kg BMI 21.9

Temp 97 F

BP 120/68

Height 170 cm

Pulse 70

Resp 16

General Appearance: the patient looks health and oriented ×4. He is in no acute distress and responding to question appropriately.
.

Skin: rashes and lesion noted. Skin is not intact

HEENT: Head: normocephalic, atraumatic, with no lesions. Evenly distributed hair. Eyes: PERRLA and intact EOMs. No scleral injection or conjunctival. Ears: there is patent canals, bilateral TMS which is pearly grey with no positive light reflex. The landmarks are easily visualized. Nose: pinkish norsal mucosa with normal turbinates, no septal deviation. Neck: supple, full ROM, no cervical lymphadenopathy, no occipital nodes, no thyromegaly or nodules. There is pinkish and moist oral mucosa. The pharynx is non-erythematous without exudate. The teeth are in good repair.

Cardiovascular: There is regular rate and rhythm in S1, S2. No production of extra sounds, no clicks, no rubs, nor murmur. There is 3+ throughout with no edema.

Respiratory: there is regular and easy respirations, the lungs is clear to auscultation bilaterally. There is symmetric chest wall.

Gastrointestinal: no abdomen obese, active BS in all the 4 quadrants, soft and non-tender abdomen. No hepatosplenomegally.

Breast: no masses or tenderness upon palpitation. No discharge, no dimple, no wrinkle. There is no discoloration of the skin

Genitourinary: non-distended bladder, no CVA tenderness. There is normal distribution of the pubic hair. Skin consistent with general pigmentation. No vulvar lesion noted and both testes palpable, no masses and lesions, no hernia, no uretheral discharge (Kim, et al., 2018).

Musculoskeletal: Full ROM noted in all the 4 extremities upon examinations

Neurological: there is clear speech, good tone, stable, and normal gait.

Psychiatric: Alert and oriented. × 4, maintaining the eye contact, soft speech, clear and normal rate and codence. Responding to the questions appropriately.

Lab Tests

Complete Blood Count: the cause of the itching skin can be due to the iron deficiency

Chest-X-rays: this help in revealing about the presence of the enlarged lymph nodes which is also characterized with itchy skin.

Skin Biopsy: reveal the cause of the growth, sore, and rash (Habif, 2016).

Special Tests: skin culture to determine the microorganism that affect the skin

Diagnosis

Differential Diagnoses

1- o Squamous cell carcinoma

2- o Benign skin lesions

3- Actinic keratosis

Diagnosis

o Basal cell carcinoma

Plan/Therapeutics

o Plan:

· Further testing: skin culture to determine the microorganism causing the skin disease. Performance of the histology to confirm the nodular basal cell carcinoma

· Medication: prescription creams, topical anti-tumor medication and chemotherapy, photodynamic therapy, and the electrosurgery and the wide local excision

· Education: patient educated to avoid potentiating factors for example the sun exposure, arsenic ingestion, tanning beds, and the ionizing radiation

· Non-medication treatments: cryotherapy, curettage and electrodesiccation, laser surgery, and the radiation therapy (Ely et al., 2014).

Evaluation of patient encounter: the patient is alert and well-oriented but is concerned about his condition that makes him uncomfortable. She is not aware of the condition and the type of medication to be used or how to prevent the exposure to risk of worsening his condition. The patient requires proper education and medication.