| Date: 10/16/2023
Time: 9:30 am
Vital Signs: Height: 5’5″, Weight: 160 lbs, Temp: 98.1°F, B/P: 148/80 mm Hg, Pulse: 75 bpm, Respiratory rate: 19 breaths per minute
Subjective
History of Present Illness symptoms: Ms. Smith, a 65-year-old Caucasian female, presented for a follow-up appointment with a history of unstable angina, characterized by recurring chest pain, shortness of breath, and fatigue, and concerns about its increased frequency. She also has a diagnosis of pure hypercholesterolemia, managing it with occasional concerns about statin-related muscle aches. Additionally, she reported ongoing respiratory difficulties due to her chronic obstructive pulmonary disease (COPD), including nighttime shortness of breath and occasional forgetfulness in using her prescribed albuterol inhaler. These comorbidities have significantly impacted her daily life, and she is motivated to improve her management strategies for better symptom control and quality of life.
Current Medications: Aspirin 81mg daily, orally; Albuterol inhaler PRN; Atorvastatin 20 mg OD orally
Medication allergies: NKDA
Social History: She is married, has a family, and is currently not working, likely retired, as there is no mention of occupation. She is an immigrant from Mexico, which may have cultural and language implications for her healthcare. She reports no alcohol consumption, smoking, or illegal drug use, and her hobbies and exercise routines are not detailed, possibly suggesting limited leisure activities. Her social history highlights her familial and cultural background, as well as her lack of engagement in certain health-risk behaviors.
Family History: Ms. Smith’s family history reveals a significant cardiovascular risk on her paternal side, with her father experiencing a heart attack and her paternal grandfather suffering from a stroke. On her maternal side, there’s a history of type 2 diabetes, as her mother and maternal grandmother both had the condition. Additionally, there is a family history of cancer, with her paternal aunt having breast cancer and her mother’s sister being diagnosed with ovarian cancer.
Review of systems:
General: The client is obese and presents with difficulties in breathing and abnormal heart sounds.
Eyes: She is myopic and uses eye aids
Ears: Reports tinnitus in her right ear
Nose: Denies any nose conditions
Mouth/Throat: She cannot remember the last time she visited a dentist. She has lost two of her teeth in the upper jaw.
Cardiovascular: Reports chest pain and palpitations. There is easy fatiguability with minimal exertion or activity
Respiratory: Reports difficulties in breathing, shortness of breath, cough, and wheezing
Gastrointestinal: Denies stomach pain. No recent stomach upsets.
Genitourinary: Reports frequent urination, with no pain on urination
Musculoskeletal: Reports pain in the right leg joints
Skin: Denies skin rashes or any skin conditions
Breasts: Denies breast pain or discharge
Neurological: Reports intermittent mild headaches
Psychiatric: Denies depression anxiety, reports trouble sleeping
Endocrine: Denies thyroid disease and heat intolerance.
Objective
General: The client is cooperative and talkative
Skin: Dry skin, warm, no scars visible
Hair: Dry, well-groomed
Nails: Nails are cut short and well-kempt
HEENT:
Head: Normocephalic and atraumatic noted
Eyes: No discharge, redness, or abnormalities observed
Ears: shape bilateral equal, no inflammation, tympanic membranes pearly grey, poor external hygiene
Teeth/Gums: Two missing teeth visualized in the upper jaw
Pharynx: Mucosa non-inflamed, posterior pharynx is normal
Neck: No lesions observed. No distended veins were noted.
Heart: There is an apparent murmur heard.
Lungs: Wheezing, rhonchi, and decreased lung sounds auscultated.
Abdomen: Regular bowel movements are heard on all the four quadrants
Back: The patient has kyphosis
Rectal: Not examined
Extremities: Edema noted on the right lower limb
Musculoskeletal: Normal range of motion, no misalignment
Neurologic: Alert and oriented x 3, normoreflexia
Psychiatric: The patient is in a euthymic mood
Pelvic: Not examined
Breast: No masses, discharge, or abnormalities noted
Assessment:
Recurring chest pain
Shortness of breath
Fatigue
ICD-10 Codes
I20.9 – UNSTABLE ANGINA
E78.0 – PURE HYPERCHOLESTEROLEMIA
J44.9 – CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED
CPT Codes:
99203 – OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; MODERATE LEVEL MED DECISION; 30-44 MIN
Plan:
Regularly monitor vital signs, including blood pressure, heart rate, and oxygen saturation, to assess the patient’s cardiovascular and respiratory status.
Conduct lipid profile tests and adjust statin therapy as necessary to achieve target cholesterol levels.
Assess respiratory function with pulmonary function tests (spirometry) to guide COPD treatment decisions.
Ensure patient adherence to prescribed medications, including antiplatelet agents, bronchodilators, and statins.
Educate the patient on recognizing angina and COPD exacerbation symptoms and encourage lifestyle modifications.
Periodically conduct blood tests to assess liver function, creatinine levels, and inflammatory markers to monitor the patient’s overall health and treatment safety.
Follow-up:
Follow up in two weeks to discuss lab results and review medications in case adjustments are needed. |
