CC: right foot pain for three days. 5/10 intensity on the pain scale.
This is a 58-year-old male with PMH of HTN, HLD, GOUT, ESRD, CVA right side with Hemiplegia-wheelchair bound, HTN, CKD-4 on Dialysis 3x/week, Who presents to the office for regular follow-up. He complains of right foot pain for three days. 5/10 intensity on the pain scale, described as intermittent shooting pain, alleviated by rest and OTC medications, aggravated by mobility, pain does not radiate to another region. No trauma. The patient denies SOB, chest pain, palpitations, headaches, or dizziness. The patient has no new complaints. Urinate once a day. He is not taking medication on Tuesday, Thursday, and Saturday on dialysis.
O: VS BP: 150/100 mmHg (right arm, seated), Heart Rate: 96 bpm, Respiratory Rate: 18 breaths per minute Temperature: 98. 3°F, Spo2: 100%, Room air, Weight: 177 lbs. (BMI: 23.1 kg/m2) (dressed), Height 6ft. 5in. (Without shoes).
OBJECTIVE:
Vital Signs: Ht(without shoes) 172 cm (5’8”). Wt. (dressed) 58.51 kg (184 lbs.) (BMI: 28.0 kg/m2) BP 120/60 mmHg (right arm seated); 125/62 mmHg (left arm, seated); with wide cuff. Heart rate (HR) 70 bpm and regular. Respiratory rate (RR) 18 bpm. Temperature (oral) 97. 9°F, Spo2: 100% Room air.
HEENT : Positive for runny nose, watery eyes, and sore throat. Denies earache or dizziness.
Eyes: Vision 20/20 in both eyes. Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm. PERRLA. EOMI. Disc margins are sharp, without hemorrhage or exudate: no arteriolar narrowing or A-V nicking.
Ears: Ear canal clear bilaterally. TM clear bilaterally; bilaterally Ear good cone of light. The cone of light is at 5 o’clock in the right ear and 7 o’clock in the left ear. Rinne test: Positive bilaterally (AC > BC). Weber midline: No lateralization. Mastoid process: No tenderness noted bilaterally.
Nose Mucosa pink, septum midline. No sinus tenderness. No polyps, turbinate intact, no evidence of bleeding.
Mouth: Oral mucosa pink. The dentition is good. Tongue midline. Tonsils 1+. Pharynx without exudates.
Neck: Neck Supple. Trachea midline. The thyroid isthmus is palpable, and lobes are not felt.
Lymph Nodes: No cervical, axillary, or epitrochlear nodes.
Thorax and Lungs: Thorax Symmetric with good expansion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Respiratory : Positive for a productive cough with yellowish sputum. Denies shortness of breath (SOB).
Cardiovascular: Regular rate and rhythm, heart rate 70 bpm. Crisp S1 and S2. At the base, S2 is louder than S1. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.
Abdomen: soft, non-tender + BS, no guarding.
Diagnostics:
Assessment:
Plan:
Pharmacologic:
Medications:
BENAZEPRIL HCL 40 MG TABLET: take one tablet (40 mg) by oral route once daily
METOPROLOL SUCC ER 200 MG TAB, take one tablet (200 mg) by oral route TID
LOW DOSE ASPIRIN EC 81 MG TAB, take 1 tablet (81 mg) by oral route once daily
PRAVASTATIN SODIUM 40 MG TAB: take one tablet (40 mg) by oral route once daily f
ALLOPURINOL 300 MG TABLET: take one tablet (300 mg) by oral route once daily
COLACE-T 100 MG CAPSULE, two tablets oral once daily
COLCHICINE 0.6 MG TABLET: take one tablet (0.6 mg) by oral route once daily
AMBIEN 10 MG TABLET (take one tablet (10 mg) by oral route once daily at bedtime)
Education:
Nonpharmacologic
follow-up
referral
NOTE
· Any diagnostics ordered/planned (this would be diagnostics needed)
· The patient was prescribed Polymyxin B/Trimethoprim solution one drop q 4 hours while awake x7 days. (also enter quantity # here if controlled substance or antibiotics)
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