Patient Initials:

Pt. Encounter Number:

Date:

Age:

Sex:

Allergies: Advanced Directives:

SUBJECTIVE

CC:

In quotation marks indicate the patient’s complaint

Follow the example. You must address the fundamental aspects of the patient, such as age, complaint, symptoms, time with symptoms, health problems …

HPI:
Mr. FG is 71 years old male patient who presents today for the annual wellness visit. He was well oriented in time, place and person. He did not report any kind of illness except occasional lower back pain, after all he is suffering from a number of chronic conditions but he is taking proper guidelines and working on them. He denied any type of mentally or behavioral illness. He denied fever and chills, nausea and vomiting. The patient is living with his family happily.

Current Medications:

Indicate if the patient is consuming any medication.

Follow the lead according to the disease

PMH

Medication Intolerances:
None

Chronic Illnesses/Major traumas:
Cardiac cath, “Operated 2007”.

Screening Hx/Immunizations Hx:
No history of immunization. Rheumatoid factor. Urinary analysis. Angiography. Chest X-rays. Dexa scan. Ekg, Dental exam, eye exam, colonoscopy, spirometery.

Hospitalizations/Surgeries:
Hernia repair 1975, RT knee replacement 2004, fistulectomy 1975, partial prostatectomy 2014.

Family History
: Father died of hemorrhage, Ulcer, gastric

Mother died of kidney disease.

Social History:
Ex-smoker, drink on and off.

Follow the lead according to the disease In this case, the symptoms should focus on “Genitourinary / Gynecological” and other related systems- symptoms that the patient refers to their disease.

You must use different wording to complete “ROS”

ROS

General

Alert no change in physical appearance, strength, weight and no fever and chills

Cardiovascular

No chest pain, no palpitations, no orthopnea. Regular rhythm, pulse rate normal

Skin

Normal

, in color, no lesion, no rash.

Respiratory

No cough, sputum, chest normal in shape, no abnormal breathing sound.

Eyes

Normal vision, denied any pain and blurred vision

Gastrointestinal

Normal appetite, normal bowel habit.

Ears

Denied from vertigo, change in hearing, tinnitus.

Genitourinary/Gynecological

Nose/Mouth/Throat

Nose: No obstruction. No discharge, denied bleeding, no epistaxis.

Mouth: normal mucosal lining.

Throat: Normal in shape, no abnormal mas found.

Musculoskeletal

Occasional lower back pain, denied any joint or muscle pain.

Breast

Normal

Neurological

Intact sensory and motor system, normal DTR

Heme/Lymph/Endo

Normal, no swelled lymph nodes.

Normal thyroid gland.

Psychiatric

Normal, denied any type of psychiatric issue.

OBJECTIVE Follow the lead according to the patient

Weight 174 lb. BMI 30.82

Temp 97.90 F

BP 139/78 mmhg

Height 63”

Pulse 64 bpm

Resp 18bpm

PHYSICAL EXAMINATION Follow the lead according to the disease

General Appearance

Alert and oriented x 3. The patient is well-groomed, who responds to questions quickly and appropriately. She is dress appropriate to the occasion and has a normal posture.

Normal in color and texture

HEENT

Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. No aphasia receptive or expressive. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movement intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions. Lids non-remarkable and appropriate for race. Neck negative for masses, no noticeable or palpable swelling, redness or rash around throat or on face. No thyromegaly. No JVD distention. Teeth are in good repair

No splitting of the heart sounds heard. No murmur. No S3 or S4. No friction rubs. Patient denies chest pain. S1, S2 with regular rate and rhythm. No extra heart sounds. No SOB, no JVD, no carotid bruits.

Symmetric chest walls. Respirations regular and easy. Clear to auscultation, no use of accessory muscles, no crackles or wheezes.

Abdomen flat, soft, no painful to palpation. BS active in all 4 quadrants. No hepatosplenomegaly

No mass noted, no fulness sensation, pain, or discharge reported. No prior history of breast biopsy, lesions, pain, or discharge.

Genitourinary

No history of falls reported, denies weakness, muscular pain, swollen ,or any other inflammatory symptoms in the joints. Denies joint pain, limited ROM, difficulty walking, or trouble reaching above head.

Denies history of seizure disorder, stroke, head injury, tremors, or involuntary movements, vertigo, spinal cord injury, meningitis, blackouts, paralysis, fainting, dizziness, numbness, or loss of sensation. The memory is good.

Patient states no changes in mood, denies anxiety, depression, or insomnia. Denies low self-esteem, feeling sad, social isolation, or attention deficit, no change in thought patterns.

Lab Tests Follow the lead according to the disease

MRI of back, X-ray of spine, CBC, Urinary analysis, Lipid profile.

Special Tests: Follow the lead according to the disease

X-ray of Spine, MRI of lumber spine.

Diagnosis Follow the lead according to the disease

· Primary Diagnosis Follow the lead according to the disease

Abscess of bartholin’s gland (ICD 10-N 75.1): Bartholinitis occurs when the ostium duct of Bartholin’s gland is blocked, and it becomes infected. If the cyst is small and there is not infection usually it is asymptomatic but, ones the cyst increases in size, or become infected, patients start to feel a tender, painful lump near to the vaginal opening. Usually the pain and discomfort increase with walking and sitting, and patients also present dyspareunia and fever. Based on the patient’s subjective assessment, I suspect that the patient is the holder of this condition (Charleton, Otero, Giorgi & Tyndall, 2016).

· Differential Diagnosis (minimum 3 differential diagnosis and 3 references) Follow the lead according to the disease

Trichomoniasis (ICD 10-A59.01): Sexually transmitted infection of the urogenital tract is a common cause of vaginitis in women, while men with this infection can display symptoms of urethritis. ‘Frothy’, greenish vaginal discharge with a ‘musty’ malodorous smell is characteristic.
Herpes viral infection of the urogenital tract. (ICD 10-A60.09): It is a sexual transmitted disease caused by the infection of Herpes Simplex Virus Type 2. It is characterized by the develop of sores which look like blisters around the genitals, or the skin surrounding the rectum with pain and itching. Usually patients present Flu-like symptoms such as fever, weakness and cough before the lesions appear. After the primary infection, most of the cases suffer sporadic episodes of viral activation or outbreaks, the frequency and severity of the outbreaks are related with the patient’s immune status and the efficacy of the treatment (Lee, Dalpiaz, Schwamb, R., Miao, Waltzer & Khan, 2015).
Gonorrhea (ICD 10-A54.9): The clinical presentation in the female patient, is characterized by yellowish or gray-brown, purulent vaginal discharge, and accompanied by itching and dysuria; may be accompanied by abdominal pain. May be accompanied by mild dysuria and urethral itching. On physical examination of female patient, findings are usually scant to copious purulent vaginal discharge and this patient has symptomatology that suggests this condition, although she does not have the complementary exams at hand to establish the diagnosis (Kessous, et.al, 2018)

PLAN including education Follow the lead according to the disease
o Plan:
 Further testing
X-ray of D spine after 1 month.
 Medication
Vitamin C 500mg oral OD.
Vitamin D and Calcium supplement 500mg OD.
Acetaminophen 50mg TD
 Education
Discussed risk factors and complications of deformity with patient
 Non-medication treatments
Asked him to start physical activity
· Referrals
Physiotherapist
 Follow-up visits
After one month in OPD

References:

Clinic, M. (2020, June 11). Kyphosis. Retrieved from MayoClinic: https://www.mayoclinic.org/diseases-conditions/kyphosis/symptoms-causes/syc-20374205
clinic, M. (2020, June 12). Kyphosis-Diagnosis and Treatement. Retrieved from MayoClinic: https://www.mayoclinic.org/diseases-conditions/kyphosis/diagnosis-treatment/drc-20374209
webMD. (2020, August 11). Anemia. Retrieved from WebMD: https://www.webmd.com/a-to-z-guides/understanding-anemia-basics#1
White, C. (2019, September 5). What is Kyphosis, Outlook, causes, treatment. Retrieved from Healthline: https://www.healthline.com/health/kyphosis