Title: Patient Write up and Health Promotion Recommendations Instructions: your write up: you should have already conducted your interview and have a draft of the (subjective documentation), you will be writing up your physical exam (objective documentation), formulating your medical diagnosis (collaborative diagnosis)

Patient identification

Name: D. A

Age: 54

Race: White

Gender: Male

Subjective Data

Chief Complaint (CC):

Patient presented to the clinic today with complaints of heart palpitations

History of Present Illness (HIP)

Mr. Drew is a 56 years old male who presents at the Cape Cod clinic today with complaints of heart palpitations. The patient reports that the heart palpitations started about a week ago, and he first noticed the symptom while he was at the gym. He states that the palpitations come and go, and each episode last about 10-15 minutes. He states that the palpitations are about a 7/ 8 out of a 0-10 scale, when he has it. He denies having palpitations during clinic visit. He describes the palpitations as “it feels like my heart is going to come out of my body”. He denies taking any medications to alleviate symptoms; he states that the palpitation goes away on its own. He reports that the palpitations are aggravated by increased activity and anxiety.

Medications

Patient is under no medication

Allergies

Penicillin-Patient gets a rash as an allergic reaction to penicillin

Past Medical History

Patient has in the past experienced sudden sensations of spinning, which is triggered mainly when the patient is in motion. Patient claims having dizzy spells, where he feels as if the world around him is spinning.

Social History

Patient works full time as a Truck Driver. Denies ever smoking tobacco. Drinks on weekend’s socially, about 3-4 drinks. Denies use of illicit drugs. Patient attends to the gym 3- 4 times a week.

Family History:

Mother: Hypothyroid. Hypertension

Father: Hypertension. Hyperlipidemia

Sister: is healthy at 41-year-old age

Maternal Grandmother: Hypertension. Hypothyroid. Hyperlipidemia

Paternal Grandfather: Died at age of 88 years old with an MI

Review of Systems (ROS)

General: No abnormal changes in weight, fatigue, weakness, fever, chills, and night sweats.

Head: No history of trauma or headaches

Eye: No changes in vision. He denies use of corrective lenses

Ears- No hearing loss, tinnitus, vertigo, discharge, or earache

Nose/Sinuses: No rhinorrhea, stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure

Mouth/Throat/Neck: No bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth.

Respiratory: No shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis, Influenza.

Cardiovascular: No chest pain. Reports new episodes of palpitations. No edema. No murmurs. No ever having an abnormal EKG. No cardiac history.

Gastrointestinal: No abdominal discomfort, tenderness, distention, ascites. NO constipation, diarrhea, dark or bloody stools. No changes in diet regimen. No heartburns, nausea, vomiting. Feeling bloated, increased burping or gas. Denies liver, spleen, pancreas, or any other GI problems.

GE: No dysuria, frequency, burning or changes in urination. No strong odor in urine. No kidney problems, UTIs or bladder incontinence

Musculoskeletal: No muscle weakness, joint stiffness, gait changes, pain, joint instability, or swelling. No difficulties with range of motion. Denies numbness, tingling, or radiation. No previous musculoskeletal injuries or fractures.

Neurologic: No loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, seizures, change in mental status, or memory changes.

Skin:  No skin changes, jaundice, cyanosis, rashes, moles, bruises, wounds, or any open areas

Objective Data

Vital Signs- Temperature- 98.6 orally. RR- 18. O2 saturation reading- 100% RA. Heart Rate- 98. BP- 130/69. Weight- 102 kg BMI 28

General survey- Patient is alert x3. Well groomed. Well nourished. Good posture. Pleasant. Answers all questions appropriately and maintains eye contact throughout interview. No acute distress

Skin, nails and hair- Skin is pink, dry, thin, and warm. No cyanosis and no jaundice. Fingernails are rounded, pink and firm. No clubbing. Toenails are pink, flat and pink. No clubbing. Skin turgor- no tenting. Hair/scalp- well distributed. No masses, no lesions