%PM, %942 %27 %2017 %14:%Jul

The Zwolak Collection

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I sort my phrases like this:

.h_ : hpi

.e_ : exams

.p _ : procedures

.ap_ : assessment and plans

HPI:

DM2

DM2:

No dry mouth, polyuria, polydipsia.  Medication compliance: _.

Blood glucose:

Fasting:        _ of 7 high (max: _ )

Breakfast:   _ of 7 high (max: _ )

Lunch:          _ of 7 high (max: _ )

Dinner:        _ of 7 high (max: _ )

Vaccine: _ Pneumovax, _ Tdap, _ Flu.

Foot exam: Date: _ ; Concerns today: _ ; Checks feet at home: _

Retinal scan: Date: _ : Abnormalities: _

Meds: Metformin, _

WWE:

_ yo F G_P_ Menarche _

1. Pap: Last pap: _ Abnormal pap: _ Menses: _ Vaginal complaints:

2. Breast: Last mammo: _ Abnormal mammo: _ Lumps: _ Discharge: _ Family hx breast cancer: _

3. Bone: DEXA: 6/14 osteopenia Calcium intake: _

4. Sex/Contraception:

5. Domestic violence:

Cold:

_ yo _ w/ _ day h/o of _, nasal sx: _ ear pain: _ ST: _ Cough: _ Fever: _ Rhinorrhea: _

Tx: _

Flu shot: _ Tobacco exposure: _ Sick contacts: _

Depression:

1. Depression:
Sleep:
Interest:
Guilt:
Energy:
Concentration:
Appetite:
Psychomotor:
Suicidality/Homocide:

Treatment:
Support:

 

ROS:

Constitutional: No Weight Change, No Fever, No Fatigue
ENT/Mouth: No Nasal Congestion, No sore throat, No Rhinorrhea
Eyes: No Vision Changes
Cardiovascular: No Chest Pain, No SOB, No Palpitations
Respiratory: No Cough, No Dyspnea
Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, No Constipation
Urinary: No Urinary Frequency, No Dysuria, No Urgency
Musculoskeletal: No Arthralgias, No Myalgias
Skin: No Skin Lesions
Neuro: No Weakness, No Paresthesias
Psych: No Anxiety/Panic, No Depression, No Insomnia
Heme: No Bruising, No Bleeding
Endocrine: No Temperature Intolerance, No hair loss

 

EXAMS:

General:

Gen: NAD, age appropriate.
ENT: TM clear, nares clear, pharynx clear
Lymph: No cervical lymphadenopathy
Endo: Normal thyroid
CVS: RRR, nml PMI, no M/R/G
Pul: CTA, no W/R/R, no fremitus
Abd: +BS, soft, NT, ND
Ext: no C/C/E
Psych: affect normal

 

Back pain

MSK: TTP: Back ROM (degrees): Flex: _ Ext: _ Side Bend: _ Rotation: _
Strength:
Right: HF: 5/5 Q: 5/5 H: 5/5 PF: 5/5 EHL: 5/5
Left: HF: 5/5 Q: 5/5 H: 5/5 PF: 5/5 EHL: 5/5
Neuro: DTR:
Left: L3/4: 2/4 S1: 2/4
Right: L3/4: 2/4 S1: 2/4

Sensation: Left: _ Right: _

DM foot:

Monofilament Foot Exam
Right Foot :
Great toe Normal
1st MT Normal
3rd MT Normal
5th MT Normal
Heel Normal

Pedal Pulse Normal

Left Foot
Great toe Normal
1st MT Normal
3rd MT Normal
5th MT Normal
Heel Normal

Pedal Pulse Normal

Skin :
Ulcers Normal
Calluses Normal
Edema Normal
Onychomycosis Normal
Charcot foot Normal
Erythema Normal
Check feet at home: YGen: NAD, age appropriate.
ENT: TM clear, nares clear, pharynx clear
Lymph: No cervical lymphadenopathy
Endo: Normal thyroid
CVS: RRR, nml PMI, no M/R/G
Pul: CTA, no W/R/R, no fremitus
Abd: +BS, soft, NT, ND
Ext: no C/C/E
Psych: affect normal

Knee

Gen: NAD
Skin: Knee no calor, effusion, rubor
MSK: neg lachman, A/P drawer, mcmurray, varus/valgus gap, patellar grind.

Neuro

Neuro:
CN II-XII grossly intact, EOMI, PERRLA

DTR: Ach Pat Bi Tri BR
Right: 2+ 2+ 2+ 2+ 2+
Left: 2+ 2+ 2+ 2+ 2+

(_ right, _ left) babinski; (_)clonus; (_)hoffman's; (_) Rhomberg

MM Str: HF Q H DF PF EHL | D T B WE FF IO
Right: 4 4 4 5 5 5 | 5 5 5 5 5 5
Left: 2 2 2 0 1 0 | 2 2 2 2 0 0
Sensation: grossly intact to light touch throughout

TRANSFER/GAIT: deferred, difficulty performing with PT

Newborn:

Gen: healthy appearing newborn in no distress
HEENT: no caput or cephalhematoma, normal ears: no pits or tags, nares patent; fontanelles level
Eye: Red reflex present & equal
Clavicles: no crepitus noted
Mouth: Lip and palate intact, good suck
Pul: CTA Bilateral, no W/R/R
CVS: RRR, normal S1/S2. no murmur/rub/gallop
MSK: Good muscle tone, Neg Barlow, neg Ortolani
Abdomen: Soft without organomegaly or masses noted, umbilicus clean and dry
Back: Normal spine without significant sacral dimple.
Vasc: Femoral Pulse: Present and palpable equal bilaterally
Anus: Patent
Genitalia: Normal __male.
Skin: No rashes noted. Minimal sacral melanocytosis
Neuro: Intact moro, suck, and grasp, toes upgoing bilaterally

OMM:

Osteopathic:
Cranial: OA RRSL
Cervical: C4-7 RRSR C2-3 RLSL
Thoracic: T1-4 RLSR T5-9 RLSR T10-12 RLSR, ropey, hypertonic
Lumbar: L1-5 RRSR

Treatment Abbreviations: Art= Articulatory, BLT= Balanced Ligamentous Tension, CS=Counterstrain, HVLA= High Velocity Low Amplitude thrust, FPR=Facilitated Positional Release, ME= muscle energy, MFR=Myofascial Release, MI=Muscle Inhibition, RR=Rib Raising, ST=Soft Tissue.

PSYCH:
Arousal: Alert
Attentiveness: fully attentive
Appearance: well-dressed and well-groomed
Attitude: cooperative, not guarded
Activity: calm, not restless, no abnormal movements, good eye contact
Orientation: Fully oriented
Mood: euthymic, not dysphoric, euphoric, apathetic, anxious or angry
Affect: normal range, not restricted, flat, or labile
Verbal: normal expressive and receptive language function
Thought process: organized, goal-directed. Pt did not require redirection.
Thought content: no delusions, no suicidal/homicidal ideation
Perceptions: not responding to internal stimuli
Insight/Judgment: good insight, judgment appears to be good

Sports PE

BMI _ %
Gen: NAD, age appropriate.
ENT: TM clear, nares clear, pharynx clear
Lymph: No cervical lymphadenopathy
Endo: Normal thyroid
CVS: RRR, nml PMI, no M/R/G
Pul: CTA, no W/R/R, no fremitus
Abd: +BS, soft, NT, ND
GU: normal penis, testicles. No hernia. Tanner: _
Ext: no C/C/E
Psych: affect normal
Skin: acne_ Tinea pedis _
MSK:
Strength:
Upper extremity:
Right: Deltoid 5/5 Biceps 5/5 Triceps 5/5 Wrist flex 5/5 Wrist ext 5/5 Interossei 5/5 Thenar 5/5
Left: Deltoid 5/5 Biceps 5/5 Triceps 5/5 Wrist flex 5/5 Wrist ext 5/5 Interossei 5/5 Thenar 5/5

Lower Extremity:
Right: HF: 5/5 Q: 5/5 H: 5/5 PF: 5/5 EHL: 5/5
Left: HF: 5/5 Q: 5/5 H: 5/5 PF: 5/5 EHL: 5/5
Neuro: DTR:
Left: L3/4: 2/4 S1: 2/4
Right: L3/4: 2/4 S1: 2/4

Neuro: Neg rhomberg, intact finger nose

No Vision Test results this visit.
 

Upper extremity:

Skin: no effusion or calor of shoulder.
MS: Upper extremity:
Right: Deltoid 5/5 Biceps 5/5 Triceps 5/5 Wrist flex 5/5 Wrist ext 5/5 Interossei 5/5 Thenar 5/5
Left: Deltoid 5/5 Biceps 5/5 Triceps 5/5 Wrist flex 5/5 Wrist ext 5/5 Interossei 5/5 Thenar 5/5
ROM: intact
Neuro: Reflexes:
Right: Biceps 2/4 Triceps 2/4 Brachioradialis 2/4
Left: Biceps 2/4 Triceps 2/4 Brachioradialis 2/4

WWE:

Gen: NAD, age appropriate.
Lymph: No cervical, supraclavicular, axillary lymphadenopathy
Endo: Normal thyroid
Breast: Normal breast tissue. Normal nipple. Normal contour. Absent peau d'orange.
CVS: RRR, nml PMI, no M/R/G
Pul: CTA, no W/R/R, no fremitus
Abd: +BS, soft, NT, ND
GU: Normal meatus & introitus. Normal vagina. Normal cervix. Anteverted uterus. Normal adnexa.
Skin: Normal vulva, perineum.
Psych: affect normal

 

 

Preoperative evaluation :
Procedure:
( )low (X) Medium ( )High risk surgery

Date: to be determined
(X) No active cardiac conditions: Unstable coronary syndromes, decompensated heart failure, significant arrhythmias (AV block Mobitz II or higher, SVT with RVR, symptomatic bradycardia), severe valvular disease

Risk factors: ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease
(X) None present ( ) 1 or 2 () 3 or more

Symptoms: ( ) denies chest pain/pressure, dyspnea, dizziness, LOC, coughing, problems with bleeding/bruising or anesthesia before

Exercise tolerance:
(X) 4 METS without symptoms; can ascend a flight of stairs, or walk rapidly on level ground at 4mph, or run a short distance, or do heavy housework
( ) Unable to do 4 METS, <4 mets: performs light housework

Recommendations:
(X) Based on 2014 AHA/ACC Guidelines for preoperative evaluation patient faces acceptable preoperative cardiac risk for this procedure, no further evaluations or treatment needed. Defer to Surgeon regarding full discussion of the risks, alternatives, and benefits of the particular procedure

-Pre-OP labs ordered and normal (see above)
-No NSAIDs x 7 days prior to surgery
-Recommended cessation from EtOH

CHDP:
ASQ:
Communication:
Gross motor:
Fine Motor:
Problem Solving:
Personal-Social:
Interpretation / Concern / Plan:
Dental assessment performed: No problem suspected, no referral needed
Nutritional Assessment Performed: No problem suspected, no referral needed
Age appropriate anticipatory guidance was reviewed: No problem suspected
Age appropriate developmental assessment was performed: No problem suspected
Age appropriate vision and hearing assessed: No problem suspected
Age appropriate Hgb and Hct assessed: No intervention needed
Lead exposure evaluated: No problem suspected
Urinalysis: No problem suspected or Not indicated
TB risk assessed: No need for intervention
BMI Percentile: _%ile
Smoking:
- Second hand smoke exposure: Yes [_] No [_]
- The patient uses tobacco: Yes [_] No [_]
- The patient/parent was counseled about risks of tobacco use: Yes [_] No [_]
The patient is enrolled in WIC: : Yes [_] No [_]
- If yes, Ht. Wt. and Hgb and Hct checked
Vaccines: Vaccination status was evaluated. Age appropriate vaccines were recommended as follows: as above
Follow Up is recommended in _ months.

 

AP Colds:

Supportive care: Encourage fluids, activity as tolerated, honey for cough, salt water gargles, nasal saline.
Tylenol or ibuprofen as needed for discomfort or fever > 102.5
Return if no improvement in 2-3 days.

 

AP vasectomy

The patient has been counseled on the procedure as well as risks, benefits, and alternatives. The procedure is considered irreversible and if they desire it to be reversed, it will require a much more invasive surgery. The patient understands that 1 in 500 to 1000 vasectomies fail and that he will be required to use a backup method on contraception for 20 ejaculations and 3mo until sterility can be microscopically confirmed.

 

AP Well adult:

Discussed wellness, R&B of vitamins, safety, D&E, vaccines, dentist, sunblock & safe sex.

 

 

 

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