SKIN: No rash or itching.CARDIOVASCULAR: No reports of chest pain, chest pressure or chest discomfort. No reports of palpitations. RESPIRATORY: No reports of shortness of breath. No reports of cough; positive for increased salivationGASTROINTESTINAL: No reports of anorexia, nausea, vomiting or diarrhea. No reports of abdominal pain or blood. GENITOURINARY: Patient reports urinary urgency, low back pain on urination and frequency.MUSCULOSKELETAL: positive for unstable gait with pain to multiple jointsHEMATOLOGIC: No reports of anemia, bleeding or bruising.PSYCHIATRIC: Reports of depression currently on medications. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. Objective Patient ambulates with the complaint of pain to multiple joints. Noted that he is limping upon arrival to visit. Left knee 4; right knee 4; lower back 4; neck 3 on scale of 10. He reported that he saw the orthopedic doctor and suggested x-ray of the right knee be done. Braces to the right knee, no swollen. Left knee cool to touch. General: Awake, appropriate; well groomed; lethargic skin: warm, dry, intact;HEENT: Head: Normocephalic; Eyes: Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; Ears: Tympanic membranes intact, unremarkable; Nose:nares patent, unremarkable bilaterally; pharynx unremarkable tonsils 1/4 bilaterally; Throat: neck supple w/o lymphadenopathy.Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored.Resiratory: Lungs clear bilaterallyPlan Assessment is done
Refilled with all the medicationsX-ray of the right kneeOngoing PT treatment on the lower back and the neckInstructed on weight loss to reduce pressure from the knees, Instructed on the healthy diet; increase veg., and fiber, decrease fat and high carb diet. F/U in 3 weeksReassess painReview X-ray of right kneeSubjectiveMr. M. H., a 35 yr old Hispanic male here for follow up. Accompanied by sister and mother Per family pt has not received his bed, wheelchair from the company they provided and we faxed information to last time. Also reported they never got Neurontin prescribed last time from Walgreens. Reports pt has constipatient and will sometimes not have a bowel movement for a week, reports pt drinks plenty of water but may not eat enough fiber. reports pt has been anemic in the past. Reports pt is eating better.ObjectiveGen: A&OX3, no acute distress, well groomed. PERRL,sclera and cornea clear,conjunctive pinkbreathing even and unlabored with no adventitious sound Nose: Mucosa normal, no obstruction. Neck: Supple, no masses, no thyromegaly, no bruits. Chest: Lungs clear, no rales, no rhonchi, no wheezes. Heart: RR, no murmurs, no rubs, no gallops. Muscuskeletal: Wheelchair bound. General muscle weakness with stiffnessPlanH& H from Methodist Hospital from Sept was 8.7/30.2Weight loss: Per family pt eating betteContinue with vitamins
continue zofran prnPain in legs: Reorder neurontin Constipation: Take all medications as ordered, report all unwarranted side effects to clinician.
- Fall '19
- Spinal disc herniation, Low back pain