Documenting the patient encounter (PLO 5) HPI: Mr. McGregor…
Questions
Dоcumenting the pаtient encоunter (PLO 5) HPI: Mr. McGregоr is а 45 y/o M pаtient with a past medical history of hypertension, hepatitis C (s/p treatment), DM, and depression who presents with complaints of “feeling shaky.”. This started this morning. Pt elaborates by stating that he feels anxious, shaky, and restless. He reports that could not sleep well last night prior to onset of symptoms. The sensation is “all over” and not in just one location of his body. He rates this as a “6/10” in severity overall. He denies excessive caffeine use or taking any new prescription medications. Pt reports that he has not experienced anything like this before. He notes that this seems to be worsening since onset and is now constant. Pt is unsure of any exacerbating or alleviating factors. Associated symptoms include nausea without vomiting, irritability, diarrhea, and body aches. No reported gait or movement problems. The patient feels sweaty at times since waking up and a new loss of appetite that started today also. Pt denies chest pain, SOB, numbness or focal weakness anywhere, or any changes in vision. No known sick contacts recently. Further, pt goes on to report that he recently ran out of money and stopped taking fentanyl yesterday, having last used it around noon yesterday. He has been previously using fentanyl daily for 6 months. He states that besides having no money, he stopped because he wishes to get clean so he can get a new job. He has never attempted to stop or quit before. Pt reports using pills, snorting, or smoking it - but he denies intravenous or injection fentanyl use. Pt also states he ran out of his blood pressure and diabetes medications 5 days ago and could not refill these yet due to financial strains. Pt had previously been taking all of his medications daily for the last 2 months. Medications: Sertraline 25 mg daily for depression, Hydrochlorothiazide (HCTZ) 25 mg daily for hypertension, and Metformin 500mg PO BID for diabetes mellitus. No new or recent medication changes. Allergies: Sulfa drugs (causes lip and face swelling) Past Medical History: Chronic conditions: Hypertension (diagnosed 10 years ago) Hepatitis C (diagnosed 10 years ago, treated to cure with Ledipasvir / Sofosbuvir (Harvoni) 2 years ago) Depression (diagnosed 2 years ago) Type 2 Diabetes Mellitus (diagnosed 5 years ago) Hospitalizations: None Surgeries: None Immunizations: Pt believes he is up to date on his required vaccines/immunizations. Family History: Father: deceased, age 66 years old. Incarcerated for many years and does not like to talk about his father, but notes he was an abusive alcoholic. Mother: alive, 75 years old. Known hx of asthma and depression Brother: alive, age 48, Known hx of anxiety, otherwise healthy Social History: Tobacco/Vape: Daily vape use for the last 5 years (multiple times per day). Caffeine Use: Occasional cup of coffee in the morning, no change in caffeine use recently Alcohol: Pt does not drink alcohol due to a history of hepatitis C in the past. Pt reports he is scared to drink because he was told not to after being diagnosed with hepatitis C many years ago. Illicit drugs: Reports history of frequent (daily) fentanyl use (pt unsure of total daily dose) for the last 6 months. Pt shares that he started this after being prescribed oxycodone last year for hand injury (which is now healed). He reports that he obtains this from the street, “from a friend”. Pt stopped using fentanyl one day ago because he wants to get clean. Marital/Sexual: Pt is single, never married. He reports being sexually active with a new partner over the last year. States he uses condoms when sexually active. Living situation: Lives in an apartment near El Cahon Job: Previously worked in a factory recently laid off due to inability to work; was working shift work equating to long days. But now, pt is having a hard time finding a job. Hobbies/Exercise: Fixing his antique motorcycle. Likes to ride his newer motorcycle (wears a helmet). Pt does not exercise regularly and has been unable to do much activity since the back problem started. Diet: Normal diet Religion: Atheist Sleep: Normally averages 6-7 hours of sleep per night normally, but significantly less recently. ROS Constitutional: See HPI. Otherwise, pt reports chills but denies fever, unintentional or sudden weight loss or weight gain recently. Skin: Denies hair loss, nail pitting, rashes, lesions, or skin discoloration. HEENT: Admits to runny nose and sneezing. Denies sore throat, congestion, ear pain or discharge, eye pain or change in vision, or headache. Denies hearing changes, or tinnitus. No lymph node swelling reported. CV/PV: Denies chest pain or tightness, palpitations, or swelling or edema of lower extremities. No syncope or pre-syncope reported. Pulmonary: Denies SOB, coughing, wheezing, hemoptysis, stridor, dyspnea, orthopnea, or pain with inspiration. GI: See HPI. Denies constipation, abdominal pain or distention, or vomiting. GU: Denies dysuria, increased (or decreased) urinary frequency, urgency, or hematuria. Denies urinary incontinence. MSK: See HPI. Denies recent trauma within the last week. He also denies muscle weakness, joint swelling or joint pain, or difficulty moving any joints. Neuro: See HPI. Denies headaches, dizziness or lightheadedness, dysarthria, slurred speech, or focal weakness. Denies any known history of seizures or recent seizure-like activity. Psych: Denies confusion, racing thoughts, suicidal ideation, homicidal ideation or hallucinations. Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or polyphagia. Heme/Lymph: Denies any easy bruising or bleeding. Question 3: Documenting the patient encounter: [PLO 5] Based on the provided full patient history, respond to the following: (A.) Identify your suspected lead diagnosis. (B.) Then, identify and list ten (10) critical pieces of information to document in this patient’s chart for this case to support your lead diagnosis and/or decrease the probability of any other concerning diagnoses. (C.) Provide a brief rationale for each critical documentation item provided as to why you feel it is important and relevant to document in this case.
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