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; managed with diet and BG testing at home)

**Pertinent Negatives:**
- Chest pain
- Dyspnea

**Chronic Problems:**
- Diabetic polyneuropathy, stable
- Diabetic nephropathy
- COPD, mild
- CKD stage 2
- Hyperlipidemia
- MDD recurrent, moderate
- GERD, controlled with meds

**Past Medical/Surgical:**
None

**Medications:**
- Dexamethasone 0.25%: apply two times a day
- Xanax 0.5 mg: take one tablet TID prn
- Astepro 411 mcg: each nostril, QD
- Skelaxin 800 mg: QID, prn
- Neurontin 400 mg: BID, prn
- Lipitor 40 mg: QD
- Spiriva 18 mcg: prn
- Wellbutrin Sr 150 mg: QD
- Xopenex 45 mcg: 2 puffs Q8 hrs, prn
- Amitriptyline Hcl 25 mg: QHS
- Stool Softener 100 mg: BID
- Nystatin 200 mg: 5 cc swish n spit QID
- Nasonex 50 mcg: two sprays each nostril, QD
- Ultracet 37.5/325 mg: every six hours prn pain
- Nexium 20 mg: QD

**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
- Pulse: 62
- Temp: 97.6
- Resp.: 16

**Physical Exam:**
- Nose/Mouth/Throat: Mild hypertrophy of Right and Left Turbinates.
- Respiratory: Bilateral posterior decreased breath sounds and coarse breath sounds. Dry cough.
- 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.

**Assessment/Plan:**
- DM with renal manifestations, type II
- DM with neuro manifestations, type II
- Acute neck pain, continue Skelaxin
- Muscle spasms of head or neck, acute
- COPD, continues to cough, repeat PFT
- Restrictive lung disease, chronic
- Rhinitis, acute
- Chronic bronchitis with emphysema, chronic

**Orders:**
- Follow-up in six months
- Lab Studies: Comprehensive Metabolic panel (14), HGBA1C, Lipid panel

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

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