Patient Log1

Patient Logs

Patient information

G.K., 22-year-old, Female, Hispanic

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CC: “My cycles are so erratic and irregular.”

HPI: G.K. is a 22-year-old Hispanic female who presents for her first gynecological exam with complaints of irregular periods. Pt. has no previous medical hx. Pt. reports LMP was two weeks ago. Reports she only has 2-3 periods a year on average since beginning her cycles at 16 years old. Her cycles generally consist of 2-3 days of moderate bleeding in which one tampon last a few hours, followed by 1-2 days of light bleeding and spotting. 

Medications: OTC Monistat for yeast infection, OTC Ibuprofen 400 mg PO prn for cramping Daily multivitamins

PMH: No medical Hx.

Allergies: No known drug, food, latex or environmental allergies 

Immunization: Up-to-date on immunization. Considering get HPV vaccine. 

OB/GYN: Irregular menses cycle as detailed in HPI. LMP two weeks ago. Began period at age 16. Pt. denies any pregnancy at this time. 

Sexual History - Pt. engages in oral, vaginal, and anal sexual intercourse with men only Pt admits to only having 2 sexual partners in her lifetime. Pt. currently in monogamous relationship with her boyfriend of 8 months. 

Family History: Father: 42 years old; alive; GERD, obesity, diabetes Mother: 43 years old; alive; Obesity, Brother: 23 years old; Alive; no medical issues

Social History: Pt is a f/t student in college studying business management and Pt works p/t at Olive Garden as a hostess.

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OBJECTIVE 

Vital Signs: Weight 127 lbs BMI 21.8 Temp 98.1 BP 108/74 Height 5’4 Pulse 64 Resp 17 O2 sat 99%

General Appearance: Pleasant well, groomed Hispanic female in NAD

Assessment: G.K. is a 22-year-old Hispanic female presenting to the cliniuc for her first gynecological exam with complaints of irregular periods.

Lab Tests 

1. Labs: HgbA1C, LH, FSH, estradiol, Prolactin, total testosterone, free testosterone, DHEAS, TSH, Lipid panel; Results pending 

3. Urine Pregnancy Test: negative 

Differential Diagnoses 

-Thyroid Dysfunction (E07.9) – 

-Polycystic Ovarian Syndrome (PCOS) (E28.2) 

-Ovarian Tumor (C56.9) 

Plan

- Medication: 

• Provera 10 mg, 1 tab PO QHS x 10 days; 
• Continue OTC Ibuprofen 400mg PO Q 4-6 hrs prn for cramps. 

-Education: 

Patient reminded of the importance of not smoking or using tobacco. 

Pt. encouraged to continue daily exercise and eat a well-balanced diet. 

Follow-up: Will review lab results and ultrasound results at follow up appointment in two weeks; Will notify patient via phone of any critical labs or findings when received

Patient Information:

M.L., 60-year-old, Male, Caucasian

Subjective Data:

Chief Complaint (CC): lower left-sided flank pain and lower left-sided abdominal x4 days ago.

HPI: M.L. is a 60-year-old male Caucasian with no past medical history presents today with complaints of lower left-sided flank pain and lower left-sided abdominal pain which began 4 days ago. Patient also states that he was up most of the night last night with frequent urination. Nausea without vomiting, and a fever of 100.5 this morning also reported.

Current Medications: Takes no medications.

Allergies: No history of allergies to drug, food, or insects.

PMHx: Strep throat. Patient states as a child and into early adult years, frequently had strep

throat. Last recalled strep was when he was 34 years old.

Immunizations: Up-to-date. Tetanus Booster 9/2019.

Soc Hx: Patient is married with five children and four grandchildren. All children, except for his 16-year-old, currently live on their own within his current hometown.

Fam Hx: Mother is currently 90 years old- a healthy, active independent individual who has no medical problems and takes no medications. Father died at the age of 86 from Heart failure. 

Objective:

Vital Signs: Temperature: 101.0 oral, Pulse 89, Respirations 16, BP 132/84, O2 100%, Height 68in, Weight 190 lbs. BMI: 28.9 (Overweight).

General Appearance: Well groomed, well nourished, alert and cooperative, and appears to be in no apparent distress. Appropriately dressed male.

ASSESSMENT: After reviewing M.L chief complaint, along with his subjective health history, and ROS, M.L. may be suffering from a urinary tract infection.

Diagnostic tests: Urinalysis: WBCs present, positive leukocyte esterase, positive nitrates Primary Diagnosis: Urinary Tract Infection (ICD-10 N39.0)

PLAN:

Medication:

-Rx: Ciprofloxacin 250 mg PO BID for 7-14 days (Hollier, 2016)

-Fluroquinolones – considered a first line choice for UTI because of the frequency of resistant bacteria with these conditions.

Education:

Good hydration 

Empty bladder completely 

Good perineal hygiene 

Follow up: Complete resolution without complications within 2-3 days after starting treatment.

Patient Information

R.K., 66-year-old, Female, African American

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CC: Pain on posterior left hip along lateral thigh

HPI: R.K. is a 66-year-old African American male presenting with chief complaint of pain on posterior left hip along lateral thigh. Pain has been getting gradually worse and is almost constant. Aggravated by walking, bending, standing and squatting. Pain constant when standing long periods of time. 

Current Medications: Ibuprofen 200-800 mg prn for hip pain

PMHX: Unremarkable. All vaccines current. Has never had a colonoscopy. Last mammogram 5 years ago. Cholecystectomy 20 years ago. Hysterectomy 10 years ago

Allergies: Not specified

Fam Hx: Not reported

Soc Hx: Has an occasional glass of wine with dinner. Does not smoke. Retired 4 years ago as an office manager and walks approximately 1 mile a day

OBJECTIVE:

 Vital Signs: blood pressure 128/84, heart rate 80 respirations 20, temperature 98.5 height 5’3”,

weight 130 pounds. Reports pain 8/10 BMI 23.

Musculoskeletal: No pain to palpation; Antalgic gait noted when patient rises from seated position to standing and begins to walk. Active and passive ROM decreased with stiffness

ASSESSMENT: On assessment of the 66-year-old, it is evident that he is suffering from left hip fracture.

Diagnostic Tests: X-ray, CBC with differential to monitor current WBC,  BUN and Cr and hepatic panel.

Diagnosis: Left hip fracture (ICD 10 S72)

Plan: 

Pharmacologic treatment

-Cymbalta 30mg tab- SIG take 1 tablet every day.

- Tylenol 650mg tablets

-Education. Educate patient about pain management.

-Follow-ups: Follow up in one week to evaluate current pain management and laboratory testing results.

Patient Information

K.L., 65 y.o, Female, Caucasian

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CC: “I am fine”

HPI: K.L. is a 65-year-old Caucasian female admitted to this facility under a Baker Act for suicidal ideation, assaulting a nurse, and reporting urges to slap her roommate at the SNF with a belt.

Medications:

Aspirin 81 mg PO daily, Lipitor 40 mg PO HS, Coreg 6.25 mg OP BID, Cozaar 25 mg PO daily,

Gabapentin 300 mg PO TID, Keppra 500 mg PO BID, Vimpat 150 PO BID, Protonix 40 mg PO

daily, Ambian 10 mg PO HS, Melatonin 3 mg PO HS, Baclofen 20 mg PO BID, Colace 100 mg

PO daily.

Allergies: Dilantin, erythromycin, penicillin, sulfa, benzodiazepines, morphine (Rash).

PMH: HTN, irregular heartbeat, hypothyroid, diabetes mellitus, GERD, bipolar, depression, osteoarthritis, anemia, seizures, thrombocytopenia, hypercholesterolemia,

Social History: Patient denies tobacco, alcohol, or drug use. She is a retired RN.

Immunization History: Patient says she is up to date on her vaccinations.

Family History: Include history of parents, grandparents, siblings, and children.

Objective

Vitals: BP 151/78; P 84; R 18; T 98.4; 02 97% Wt 163 lbs; Ht 66 in; BMI 26.3

General: Patient is awake, alert and cooperative, and appears to be in no acute distress.

Assessment: K.L., a 65-year-old Caucasian female who is admitted to this facility under a Baker Act for suicidal ideation, assaulting a nurse, and reporting urges to slap her roommate is suspected to be suffering from Psychosis.

Lab Orders: Keppra level, thyroid panel, Vitamin B12, Vitamin D, Folate, Lipid Panel

Differential Diagnoses: Vascular dementia, Frontotemporal dementia, Lewy body dementia

Primary Diagnosis: Psychosis

Plan:

Medication orders:

-ASA 81 mg PO daily

-Lipitor 40 mg PO HS

Education: Advise pt. to attend group sessions, individual sessions, and try to avoid isolation in patient rooms.

-Follow-up: Follow up with the diagnostics within 3-5 days.

Patient Information

M. R., 50-year-old, Male, African American

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CC: Lower back pain X3 days which started after bending to pick-up

an object.

HPI: M. R. is a 50-year-old male African American patient presents to the clinic with chief complaints of non-radiating pain in R lower back X3 days which started when he bent over to pick up a 10 lb object. Patient states the pain is dull & achy, and now comes intermittently, about 4 times a day for 30 minutes, especially when he is walking around. Patient rates the pain a 7/10 when it comes. Patient states the pain improves when lying down and is not noticeable when he wakes up in the morning.

Current Medications: Patient denies use of any prescription medications, vitamins or supplements. Patient states he has used OTC acetaminophen for the past few days to help with the back pain.

PMH: Patient denies any past medical history or illness. 

Immunizations: all his immunizations are up to date

Family History: Patient denies any family history of arthritis, states parents and grandparents were “pretty fit people”, living into their 70’s and 80’s.

Social History: Patient is a printing company supervisor. Patient states he enjoys his work and has been at the same job for 20 years. He reports he is anxious to get back on the job.
OBJECTIVE

Vital Signs: T: 98.6, HR: 80, BP: 118/78 mm/Hg, RR: 18, O2: 99% on room air, Height: 5’ 10”, Weight: 153, BMI:22.

General: Alert and orientated X4. Cooperative. Communicates well and appropriately. Weight stable.

Assessment: M. R. is a 50-year-old male African American patient presents to the clinic with chief complaints of non-radiating pain in R lower back that has lasted for 3 days. Upon assessment, the possibly suffers from Acute low back pain.

Diagnosis (Dx):  Acute low back pain

Differential Diagnoses:  Disc herniation, Spinal stenosis, Compression fracture, Trochanteric bursitis.

Plan:

Pharmacological

–NSAIDS (Ibuprofen 400-600 mg QID or Naproxen 250-500 mg BID) if not contraindicated

–Acetaminophen (no more than 3-4 grams per day) if NSAID use contraindicated

Non-Pharmacological

-Apply heat

–Use of medium to firm mattress

–Begin treatment with physical therapy if lower back pain persists more than 4 weeks

Education: -Educate patient about low back pain and the high likelihood of improvement.

Follow-up -Patient advised to return to clinic in 1 month for follow-up appointment to

reevaluate low-back pain. If back-pain persists after 1 month without

improvement,

Patient Information

P.R., 55-year-old, Female, Caucasian

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CC: Sinus congestion, pressure, sore throat, headache, and productive cough that is worse at night

HPI: P.R. is a 55-year-old Caucasian, male with a past medical history notable for hypertension, diabetes mellites type 2, and hyperlipidemia. The patient present to the clinic with sinus congestion, pressure, sore throat, headache, and productive cough that is worse at night. The patient stated his symptoms started six days ago. Patient states his cough productive, producing a thin clear mucous. Cough is only at night, no cough during the day. Patient states his sinus congestion located across his nose and the top of eyebrows. His headache is located is localized to is forehead, and rates it as a 5/10.

Current medications: allopurinol (ZYLOPRIM) 300 MG tablet daily, atorvaSTATin (LIPITOR) 10 MG tablet at bedtime, Ibuprofen 200 mg PRN, Metformin (Glucophage) 500 mg PO in the morning, amlodopine (NORVASC) 5 MG daily, Eliquis 5mg PO twice daily, Cardizem (Diltiazem) 90mg SR PO once daily, and omeprazole (PRILOSEC) 40MG PO once daily.

Past Medical History: chickenpox at age 4, tonsillitis, and appendicitis. Atrial fibrillation, arthritis, hyperlipidemia, diabetes mellites type 2, hypertension, GERD, and gout. 

Allergies: Latex (rash). No food allergies, and no medication allergies. 

Immunizations: up to date.

Family History: both parents alive. Mother – diabetes, hypertension, hyperlipidemia. Father- diabetes and hypertension.

Social History: The patient has never smoked, used smokeless tobacco, or use illicit drugs. The patient does not drink alcohol. The patient is married and has five adult children.

Objective:

Vital signs: Temp: 98.9 F, RR: 18 HR: 84 B/P: 134/82 SpO2: 92%

General Appearance: Well, developed, well nourished, age appropriate. Well groomed,

interactive in no acute distress. Vitals reviewed and stable.

Assessment: 

Diagnostic Testing/Findings

Rapid strep test – negative

Mono spot- negative

Primary Diagnosis: Acute Bronchitis

Differential Diagnosis: Acute Bacterial Rhinosinusitis, Acute Rhinovirus, Viral Sinusitis.

Plan

-Reassure patient that acute bronchitis is a self-limited illness that typically resolves in one

to three weeks without specific therapy can help improve patient satisfaction and reduce

inappropriate antibiotic use.

For cough

- guaifenesin (Mucinex Maximum Strength) PO, Liquid: 200 to 400 mg every 4 hours as

needed; maximum: 2,400 mg/24 hours Disp OTC

- Nonpharmacologic therapy - throat lozenges, hot tea, honey

For fever and malaise

-Acetaminophen (Tylenol) PO Regular strength: 650 mg every 4 to 6 hours; maximum daily dose Disp OTC

Education:

-Reassure patient that acute bronchitis is a self-limited illness that typically resolves in one to three weeks without specific therapy can help improve patient satisfaction and reduce inappropriate antibiotic use.

Follow-up: Instruct patient to call office if symptoms worsen, fever, or malaise develops.

Patient Information

D.D., 24-year-old, Female, African American

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CC: Patient with complaints of foul odor vaginal discharge especially after intercourse. Also complains of burning with urination at times.

HPI: D.G. is a 24 y/o African American female who complains of almost fish-like smelling discharge from my vagina that started about a week ago. She usually notices it after intercourse. She describes the discharge as thick, tan, foul-smelling, slimy discharge. She also complains that she would sometimes have pain and burning on urination. She tried to use Monistat gel with no relief with her symptoms.

PMH: Diagnosed with asthma during childhood, resolved, currently not taking any

medications for it.

Medications: Minestrin 28-day pack

Immunizations: Up to date with childhood immunizations

Allergies: NKDA

Family History: Father with GERD and hypertension. Mother with no significant past medical history. 

Social History: Patient is a full-time nursing student. Lives in an apartment near campus with two female roommates. Has a boyfriend and in a monogamous relationship. Does not use condom, uses oral contraception.

Objectives

Vital Signs: T 98.1 BP 121/82 HR 64 RR 12 Height 5' 5" Weight 142 lbs. BMP 23.63

Appearance: Pt is a pleasant 20 y/o African American female who is awake and oriented. Well-groomed and dressed appropriately.
Assessment: D.D. is a 24-year-old African American female patient who presents to the clinic with complaints of foul odor vaginal discharge especially after intercourse. Also complains of burning with urination at times. After review of symptoms and lab tests, it is evident that she is suffering from bacterial vaginosis. 

LAB/DIAGNOSTIC TESTS/EKG: TSH, Urine pregnancy, Urinalysis, Pap smear, Cervical swab culture.

Differential Diagnosis:

Urinary tract infection, Chlamydia/ Trichomoniasis, Neisseria gonorrhoeae, Candidiasis.

Diagnosis: Bacterial Vaginosis

Plan:

Medication: Flagyl 500mg PO BID x 7 days

2. Laboratory test TSH to r/o thyroid dysfunction.

3. Will review urine pregnancy, pap smear, and vaginal cultures. Will notify patient of any abnormal

results.

Patient Education:

1. Finish the entire course of antibiotics for treatment, even if the symptoms resolve after a few doses.

2. Avoid douching. Douching upsets the normal balance in the vagina. Douching may lead to BV

Follow-up: If the patient continues to have symptoms of BV after finishing the medicine, or if she has any questions, she should make an appointment with the office.