VISIT TYPE: Office Visit
DOS: 02/02/20XX

Reason(s) for visit:
1. Check-up
2. Review lab work
3. Rhinorrhea for three weeks
4. Neck pain
5. Cough and phlegm for more than two years
6. Diabetes: Stable. Risk factors: obesity and age. She manages with diet and BG testing at home.
(Diagnosis of Diabetes is managed by diet and lab testing)
Pertinent negatives include chest pain and dyspnea. Patient is compliant with follow-up appointments and educational materials.

Chronic Problems:
- Diabetic polyneuropathy, stable
- Diabetic nephropathy
- COPD, mild
- CKD stage 2
- Hyperlipidemia
- MDD recurrent, moderate
- GERD, controlled with meds (Gastroesophageal reflux disease is a digestive disease in which stomach acid or bile irritates the food pipe lining. Treated with Nexium)

Past Medical/Surgical:
None

Medications:
All current as of today
- Dexamethasone 0.25% apply two times a day
(A corticosteroid that helps prevent inflammation. Treatment helps with breathing disorders such as COPD)
- Xanax 0.5 mg, take one tablet TID prn
- Astepro 411 mcg each nostril, QD
(An antihistamine that prevents or treats nasal symptoms of rhinitis allergies)
- Skelaxin 800 mg QID, prn
(A muscle relaxant. Blocks nerve pulses in the brain)
- Neurontin 400 mg BID, prn
- Lipitor 40 mg QD
(To lower bad cholesterol and increase good cholesterol)
- Spiriva 18 mcg, prn
(A bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Used to treat COPD)
- Wellbutrin SR 150 mg QD
(An antidepressant to treat major depressive disorder)
- Xopenex 45 mcg, 2 puffs Q8 hrs, prn
(A short-acting bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Used to treat COPD)
- Amitriptyline Hcl 25 mg, QHS
- Stool Softener 100 mg BID
- Nystatin 200 mg, 5 cc swish and spit QID
- Nasonex 50 meq, two sprays each nostril, QD
(Treatment for seasonal or year-round allergies)
- Ultracet 37.5/325 mg every six hours prn pain
- Nexium 20 mg QD
(Decreases the amount of acid produced in the stomach. Treats symptoms of GERD and other chronic conditions involving excessive stomach acid)

Social History:
Smoker: Stopped cigarette smoking 10 years ago

Review of Systems:
- HEENT: Positive for rhinorrhea
- Respiratory: Positive for productive cough. Negative for dyspnea
- Musculoskeletal: Negative for bone/joint symptoms, except positive for neck pain

Vital Signs:
- BP 136/72
- P 62
- Temp 97.6
- Resp. 16

Physical Exam:
- Nose/Mouth/Throat: Right and Left Turbinates: mild hypertrophy
- Respiratory: Auscultation with bilateral posterior decreased breath sounds and coarse breath sounds. Dry cough
(Decreased breath sounds and coarse breath sounds with dry cough supports COPD)
- Cardiovascular: Regular heart rate and rhythm. No murmurs, gallops, or rubs
- Musculoskeletal: Muscle spasm in cervical spine with decreased ROM to the left more than the right
(Decreased ROM to the left more than right supports muscle spasms)

Assessment/Plan:
- DM with renal manifestations type II
- DM with neuro manifestations type II
- Acute neck pain, continue Skelaxin med
- Muscle spasms of head or neck, acute
(Treated with Skelaxin. Exam shows muscle spasms in cervical spine with decreased ROM)
- COPD, continues to cough, repeat PFT
(Chronic obstructive pulmonary disease. Chronic inflammatory lung disease that causes obstructed airflow from the lungs. Treated with Dexamethasone, Spiriva, Xopenex, and pulmonary function tests)
- Restrictive lung disease, Chronic
- Rhinitis, Acute (Lasting three weeks. Patient is being treated with Astepro an antihistamine and Nasonex)
- Chronic bronchitis with emphysema, Chronic
(Chronic bronchitis with chronic emphysema is included in COPD)

Orders:
- Follow up in six months
- Lab Studies: Comprehensive Metabolic panel (14); HGBA1C; Lipid panel
(HGBA1C lab orders are to manage diabetes or related complications of diabetes)

Document Generated By: X, MD on 02/02/20XX at 02:01 PM

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