Clinical Documentation Template
Subjective
Chief Complaint: 52 year old male present for three month follow and labs check.
HPI: A 52-year old male with PMH of Hyperlipidemia diabetes presents to the clinic for three month follow up. Patient complained of polyuria, polydipsia and polyphasia. Patient is presently taking plavix and sexagliptin. Patient denies any chest pain, fever and chills.
ROS
General: lost 15lbs in last one month, admit weakness, fatigue. Denies depression, suicide throught.
Skin: no rashes, no open wound..
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: experience syncope once a week, denies seizures, weakness, paralysis, numbness/tingling, tremors, or involuntary movements.
Pulmonary: negative hemoptysis, dyspnea, wheezing,pleuritic pain
Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness.
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
O:
Past Medical History: Hyperlipidemia, diabetes
Surgeries: Appendectomy, 2000
Hospitalizations: 2000 (for appendectomy)
Allergies: NKDA
Food, drug, environmental: None
Medications: Plavix 75 mg daily (prescribed by his PCP in INDIA as a prophylaxis to prevent Heart attack. We use Aspirin 81 mg here in USA)
Sexagliptin 5 mg daily
Family History: Gout (Father) Diabetes (Mother) .
Social History: Denies tobacco/e-cigarette and alcohol use.
Objective
Vital Signs: Temp 98.2 BP 128/90 Pulse 64 RR 18 Pain 0 Height 5’ 8” Weight 140 lb BMI 21.3 SpO2 97% @ RA
Labs: Lipid Panel
Cholesterol 272 mg/dl
Triglyceride 175 mg/dl
HDL 28 mg/dl
LDL 135 mg/dl
HgA1c 9.8%
Physical Exam:
HEENT: Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumatic. Eyes: no drainage noted, no hemorrage. Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilateral . Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddned bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline. Throat: no swelling of the lymph nodes. Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline. Neuro: Alert and oriented x 4, CN I – not tested, II-XII intact. Deep tendon reflexes 2+ Brachioradialis, bicep, triceps, supinator, knee, and ankle with plantar reflexes down-going. No clonus. Muscle strength 5/5. Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, nasal flaring. Cardio: JVP is 3cm. above the sternal angle with the head of bed elevated to 30 degrees. Carotid upstrokes are brisk without bruits. Temporal arteries have normal pulsation without tenderness. The point of maximal impulse is taping, 8 cm lateral to the mid-sternal line in the 5th intercostal space. Crisp S1 S2 without clicks or murmurs. Extremities are warm and without edema. No variscosities or stasis changes. Calves are supple and non-tender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ and symmetric. Ca refill <2 secs. Abdomen: soft flat, non-tender and non-distended. Normoactive bowel sounds. No palpable masses or hepatosplenomegaly. Liver span is 7cm in the right midclavicular line. Edge not palpable. Kidneys not felt. No CVA tenderness. MS: Full active range of motion in all joints of the upper and lower ext. No evidence of swelling or deformity .
Skin: dry skin, no open wound, feet look fine Male Genitalia: deferred
Assessment
Diagnosis: Diabetes mellitus 2, Hypercholesterolemia.
Plan And treatment : The cornerstone of therapy for all patients with diabetes is a personalized self-management program, usually developed with the patient by a diabetes education nurse or nutritionist. Diabetes self-management education and support facilitates diabetes self-care and assists in implementation and sustainment of lifestyle changes on an ongoing basis. This requires general nutrition and health lifestyle knowledge and an individualized nutrition and exercise plan based on an initial assessment and treatment goal.( ADA, 2018)
Diabetes mellitus: Stop Sexagliptin.
Start Metformin 500 BID, Glipizide 5 mg daily plus Actos 30 mg daily.
Hypercholesterolemia: Stop Plavix.
Start Lipitor 40 mg daily.
Aspirin 81 mg daily ( prophylaxis)
.
Education: Diabetes education and mentioned above plus regular exercise. For high cholesterol, the adoption of a healthier lifestyle, including a low-fat diet and a reasonable amount of aerobic exercise, will have a large impact on the prevalence of hypercholesterolemia, as well as of obesity and coronary heart disease. Patient should follow with PCP in three month.
Follow up: Three month
Reference
American Diabetes Association. Standards of medical care in diabetes – 2018. Diabetes Care. 2018 Jan; 41(suppl 1): S1-159
Try it now!
How it works?
Follow these simple steps to get your paper done
Place your order
Fill in the order form and provide all details of your assignment.
Proceed with the payment
Choose the payment system that suits you most.
Receive the final file
Once your paper is ready, we will email it to you.
Our Services
Ace Writing Center has stood as the world’s leading custom essay writing services providers. Once you enter all the details in the order form under the place order button, the rest is up to us.
Essays
At Ace Writing Center, Nowadays, students normally have extremely busy schedules. You will note that some of them have to take on some evening or weekend jobs in order to get some income that can help them to sustain in college or in the university. This can deny them a chance to write all the essays given. Others usually get bombarded with a lot of work by their lecturers. This can still delay such students from working on all their essays. However, some of them usually try to work on all these essays but end up delivering their work late. This can prevent them from graduating since most lecturers are strict on deadlines. If you want to write a business essay, the wise way is to hire an outstanding essay writing service like us, so that you can get the best results. If you are keen, you will note that many companies usually overcharge their customers. Some of them are there only to make money. And in reality, they really don’t care to build a long term commitment with students. You should not choose such companies. You should take your time and choose a reliable company to work with. Ace Writing Center is the ultimate solution for you. We have been offering our writing service for more than 7 years. This is a clear indication that you will get quality essay writing service. We have a wide range of writers who can work on any business essay that you might have. We believe in doing extensive research so that we can provide quality work to all our clients. .
Admissions
Admission and Business Papers
Have you ever had to write an admission essay for college? The majority of students face the same issues when applying to a university or college and many in such situations decide they need professional help to cope with this matter. They get in a situation when the deadline keeps coming closer but lack motivation to start because they are just not sure if their writing skills are strong enough. We have a solution for you! Ace Writing Center is the best admission essay writing service with a large professional team and years of experience in providing high-quality papers to students of all levels and faculties. The mission of our team is to help students make their dreams of entering a good college come true and that’s what we offer!.
Editing
Editing and Proofreading
Sometimes all the words for your paper just flow out of your mind and into your fingers. You type quickly at your keyboard and there they are, your beautiful words right there on the screen. But you have no idea how to polish it up. You may be wishing there was a paper writing service that offered this type of writing service. Look no more! Here at Ace Writing Center, we offer you an editing and proofreading option that you can't find anywhere else..
Coursework
College Essay Writing
In case you are familiar Ace Writing Center, you know the way to distinguish a better company from a cheap one exactly. First of all, poor service website does not have a sufficient support. We think support team is an essential part of success; it has to answer all clients’ questions and be a connecting link between clients and their writers. On our web-service you will get answers about anything you need and your writer will receive all your instructions, assignments and requirements exactly and swiftly. A writing service that we run has got a flexible pricing system that will save you from senseless wastes and many bonus systems that let you sparing money for something important for you.
