Name: Moses Sinclair

 Pt. Encounter Number: 456789

Date: 06/1/2024

Age: 68

Sex: Male

SUBJECTIVE

CC:  

“I am having pain in my right hand for 3 months.”

HPI:  

Patient complains of right hand and wrist pain and weakness for 3 months ago. “It lasts all day but not constant pain.”  “It’s an achy pain and an elecrtrical shock feeling.” Patient states the more he uses his right hand, the more it aches. Rubbing his right hand helps with the pain a little and takes a Tylenol ES during the day helps a little as well.   The pain is “pretty bad” in the afternoon, patient states, 7 out 10 on severity.  

Medications: 

Patient taking OTC Tylenol ES at this time, denies any prescribed medications, herbs or supplements; past or present

Allergies: NKDA

Medication Intolerances: None

Past Medical History: None

Chronic Illnesses/Major traumas: None, Denies any major traumas.

Hospitalizations/Surgeries: None

Family History: Diabetes and Stroke runs in family; Father-age 91, alive, Type II Diabetes and on insulin; Mother-age 90, alive, had stroke 10 years ago when she was 80, doing well. Sister-passed away at age 67 due to heart disease.

Social History:

Patient is a carpenter.  Patient lives with his wife in a single-family home. Patient denies smoking, alcohol and drug use.  Patient is sexually active.   Patient is up-to-date with immunizations.  Patient hasn’t had any cancer screenings.

Review of Systems

General 

Denies weight change, fever, chills, night sweats.  Patient c/o fatigue, feeling more tired as of late

Cardiovascular

Denies chest pain, palpitations, PND, orthopnea, and edema

Skin

 Denies delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles

Respiratory

Denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB

Eyes

Denies corrective lenses, blurring, and visual changes of any kind

Gastrointestinal

Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools

Ears

Denies ear pain, hearing loss, ringing in ears, and discharge

Genitourinary/Gynecological

Denies urgency, frequency burning, change in color of urine; sexually active, denies STDs

Nose/Mouth/Throat

Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain

Musculoskeletal

Denies back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis.

Complains of right hand and wrist pain and weakness, achy, “electrical shock” sensation

Breast

Denies lumps, bumps, or changes

Neurological

Denies syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells

Heme/Lymph/Endo

Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance

Psychiatric

Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx 

OBJECTIVE

Weight: 195 lbs (88.6kg) 

BMI: 28.8

Temp: 98.6F (36.7C)

BP:134/64 

Height: 5’9” (175 cm)

Pulse: 75

Resp: 20

General Appearance

Patient appears healthy and well-nourished in mild distress and pain.  Patient’s personal hygiene is intact, patient’s hair and teeth appear clean.  Patient is not malodorous.  Dress is appropriate for the weather.  Clothes appear clean and in good condition, no odor, stains or holes visible. 

Skin

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. 

Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection, anicteric, fundus WNL, no 

papilledema. Diabetic retinopathy.

Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized.

Nose: Nasal mucosa pink; normal turbinates. No septal deviation. 

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.  Trachea midline, mobile. No masses, JVD or carotid bruit.  

Mouth/Throat: Oral mucosa, pink and moist. Pharynx is non-erythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all the four quadrants. Abdomen soft, symmetric, nontender., (-) guarding.  No masses, no visible lesions or scars.  Liver exam – nontender to palpation.  Liver span – 10 cm, WNL.  

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

No edema, erythema, or tenderness.

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room.  Limited ROM to right hand and wrist, pain with movement, no swelling or bruising noted to right hand and wrist, bilateral radial pulses palpated, 2+, WNL, Tinel’s and Phalen’s: Positive; Pinch Test to right hand , decreased strength.

Neurological 

Speech clear. Good tone. Posture erect. Balance stable; gait normal. Cranial Nerves II-XII intact. DTR: Biceps, Corachobrachialis, Patella, Achilles 2+, WNL.  

Psychiatric

Alert and oriented. Dressed in pants and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

None

ASSESSMENT

Differential Diagnoses

PLAN

Non-Pharmacological Recommendations

Patient Education

Culture Considerations

Health Promotion

Referrals

Follow-Up

Name:  

 Pt. Encounter Number:

Date: 

Age: 29

Sex: 

SUBJECTIVE

CC:  

“I’m here because of menopausal changes to my periods. Which I’m concerned may make me impotent and never get pregnant.” 

HPI:  

The patient is a 29-year-old female presenting with concerns about irregular menstruation and difficulty conceiving. She reports her periods have been irregular for the past 11 months after discontinuing birth control. She stopped the birth control pill to try to conceive. After discontinuation, her first period was absent for 8 weeks, followed by infrequent cycles every 2-3 months. Each period is described as light, lasting only 2-3 days. She reports a history of irregular periods starting at age 13, which led to her being placed on birth control. She also mentions a noticeable increase in facial hair (particularly on the chin and upper lip), which she waxes frequently, as well as increased acne and darkening of the skin under her arms and in the groin area. She has gained approximately 20 pounds over the past two years. The patient reports trying a progesterone pill 6 months ago, but it did not regulate her cycle.

Medications: None currently, previously used oral contraceptives and progesterone pills for menstrual regulation. 

Allergies: No known drug allergies.

Medication Intolerances: None.

Past Medical History: Menstrual irregularities since menarche at age 13.

• Previous use of birth control to regulate cycles.

 Chronic Illnesses/Major traumas: None reported.

 Hospitalizations/Surgeries

• None. 

Family History

• No history of diabetes, hypertension, heart disease, or thyroid problems in immediate family.
• No known family history of reproductive health issues. 

Social History

• Non-smoker, no alcohol use or illicit drug use.
• Lives with partner, employed as a teacher.
• No safety concerns. 

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General: Weight gain of 20 lbs over the past two years. No fever, fatigue, or night sweats. 

Cardiovascular: No chest pain, palpitations, or edema. 

Skin: Increased acne, darkened skin in axillae and groin. No rashes or lesions noted. 

Respiratory: No cough, dyspnea, or wheezing. 

Eyes: No visual changes, corrective lenses not needed. 

Gastrointestinal: No abdominal pain, nausea, vomiting, or diarrhea. 

Ears: No hearing loss, ear pain, or ringing in the ears. 

Genitourinary/Gynecological: Irregular menstrual cycles, light periods, attempting conception. Last pap was two years ago, normal results. No vaginal discharge. No history of sexually transmitted diseases (STDs). 

Nose/Mouth/Throat: No sinus problems or throat pain 

Musculoskeletal: No joint pain, back pain, or stiffness.

Breast: No dimpling, wrinkling, or discoloration of the skin. No skin retraction or nipple inversion noted. 

Neurological: No seizures, transient paralysis, or weakness.

Heme/Lymph/Endo: No excessive thirst or hunger. No known history of thyroid problems.

Psychiatric: No history of depression or anxiety.

OBJECTIVE

Weight: 170 lbs BMI: 28.3 (Overweight)

Temp:  98.6°F

BP: 122/78 mmHg

Height:  5’5”

Pulse: 76 bpm

Resp: 16/min

General Appearance: Healthy-appearing adult female in no acute distress. Alert and oriented, cooperative with a slightly somber affect initially but brightened later.

Skin: Brown, warm, dry, no rashes or lesions noted. Darkened skin in the axillae and groin areas.

HEENT: Head normocephalic, atraumatic. PERRLA, EOMs intact. No conjunctival or scleral injection. Ears clear, TMs pearly gray. Oral mucosa pink and moist, no lesions.

Cardiovascular: S1, S2 with regular rate and rhythm. Pulses 3+ throughout. No edema.

Respiratory: Clear to auscultation bilaterally. Symmetrical chest expansion.

Gastrointestinal: Abdomen soft, non-tender, obese, BS active in all four quadrants.  

Breast: Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary: No adnexal masses or tenderness. Cervix nulliparous, well estrogenized. No vulvar lesions. 

Musculoskeletal: Full ROM in all extremities, no joint swelling or deformities.

Neurological: Alert, oriented, no motor or sensory deficits noted. Gait normal.

Psychiatric: Cooperative, normal mood and affect.

Lab Tests

• Urinalysis (point-of-care test): nitrites and blood are present, but leukocytes are not.
• Urine culture: Done in the office and sent to the laboratory lab to wait for results.
• Wet prep: Information was collected in the workplace and sent through the lab until the results were ready.

Assessment 

Polycystic Ovary Syndrome (PCOS)

PCOS is a common condition affecting women in the child bearing age that manifests in different ways like delayed menstruation, obesity, acne, hair growth, and darker skin. The patient's periods have been erratic, more so since she discontinued birth control. Not long ago, they put on weight, and now their acne gets worse. These represent all symptoms of PCOS. Anovulation, or not ovulating, renders it harder to get pregnant because it makes periods happen less often. It is a sign of PCOS. It was also found that the person had hirsutism, meaning they had extra hair on their chin and upper lip, as well as darkening under their arms and in their thighs. According to Siddiqui et al. (2022), PCOS has many reasons, such as genetic and situational ones. Also, insulin resistance is often linked to this condition, which can make obesity and periods that fail to appear on time worse.

Hypothyroidism

The person may gain weight, have periods that don't come on time, and see changes in their skin. These are all signs of hypothyroidism, a medical condition whereby the thyroid gland doesn't work properly. Thyroid hormones are very important for controlling metabolism and ensuring overall health during pregnancy. Insufficient amounts of these hormones can mess up the menstrual cycle, causing periods to come and go or even amenorrhea (Itriyeva, 2022). Less biological exercise can lead to weight gain, which usually happens slowly. Due to poor circulation and slower skin growth, hypothyroidism can also cause changes in the skin, like it getting dry and darker. Finding out if hypothyroidism is the reason of the patient's symptoms would require a thyroid function test that measures blood amounts of thyroid-stimulating hormone (TSH) and free T4.

Hyperprolactinemia

Hyperprolactinemia is an illness where there are too many prolactin levels in the body. Because it stops ovulation, it can cause periods to be unpredictable and impotence. Prolactin is responsible for breastfeeding, but excessive levels of it may inhibit the secretion of gonadotropin-releasing hormone (GnRH). This ceases the generation of luteinizing hormone (LH) as well as follicle-stimulating hormone (FSH), which are both needed for ovulation to happen normally (Papadakis et al., 2020). High levels of prolactin may be to blame for the patient's irregular periods and failure to get pregnant. High levels of prolactin usually lead to anovulation and infertility. There are other signs that hyperprolactinemia can cause, such as galactorrhea, which is a condition where you make milk without trying to. In this case, though, this wasn't said. A blood prolactin test could assist to confirm this diagnosis and figure out the next step in treatment.

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Final Diagnosis:

Hypothalamic Amenorrhea 

Hypothalamic amenorrhea happens when the hypothalamus is affected by things like stress, big fluctuations in weight, or intense exercise. The hypothalamus handles chemicals that are required for pregnancy as well as menstruation. Period problems, light bleeds, and challenges getting conceived after discontinuing birth control are all signs that the brain fails to transmit chemicals properly. According to Podfigurna & Meczekalski (2021), not ovulating, gaining weight, and other symptoms like acne and face hair growth may be signs of an underlying chemical imbalance that is affected by the hypothalamus. Though Polycystic Ovary Syndrome (PCOS), hypothyroidism, and hyperprolactinemia were thought of as possible causes, the patient's history of irregular periods after stopping birth control, no ovulation, and no clear cysts on the ovaries point to a hormonal problem at the central level rather than problems with the ovaries or thyroid.

Plan

Medications:

• Oral contraceptive pills (OCPs) or a combination of estrogen and progestin therapy to regulate the menstrual cycle.
• Metformin could be considered to help manage insulin resistance, commonly seen in PCOS patients.

Non-pharmacological recommendations: Weight management through a balanced diet and exercise plan. Weight loss may help regulate periods and improve fertility.

Diagnostic Tests:

• A scan of the pelvis to look for ovarian cysts.
• Levels of serum testosterone, LH/FSH, fasting glucose, and insulin to confirm PCOS.
• Levels of TSH and prolactin to rule out problems with the pituitary gland and thyroid.

Patient Education: The patient was taught about PCOS, how it can cause infertility, and how important it is to control their weight. We talked about different fertility treatments that could help people get pregnant.

Health Promotion: Encouraged lifestyle changes, including a healthy diet and regular physical activity.

Referrals: Refer to endocrinology or reproductive endocrinology for further evaluation and management of PCOS-related infertility.

Follow-up: Schedule follow-up in 3 months to assess the efficacy of the treatment and lifestyle modifications. Further evaluation of fertility status may be necessary.

Name:  

 Pt. Encounter Number:

Date: 

Age: 

Sex: 

SUBJECTIVE

CC:  

Reason given by the patient for seeking medical care “in quotes”

HPI:  

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.

Medications: (List with reason for med )

Allergies: (List with reaction)

Medication Intolerances:

Past Medical History:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?” 

Family History

Does your mother, father, or siblings have any medical or psychiatric illnesses?  Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General 

Weight change, fatigue, fever, chills, night sweats,  and energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, and edema

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB

Eyes

Corrective lenses, blurring, and visual changes of any kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools

Ears

Ear pain, hearing loss, ringing in ears, and discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDs

   Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

  Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis

Breast

SBE, lumps, bumps, or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells

Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx 

OBJECTIVE

Weight                BMI 

Temp 

BP 

Height 

Pulse 

Resp 

General Appearance

Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later.

Skin

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.  

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are nonpalpable. 

(Male:  Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)

(Rectal as appropriate:  No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm). 

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room.

Neurological 

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes.

Urine culture collected in office—pending results, sent to lab

Wet prep collected in office—pending results, sent to lab

Assessment 

• Include at least three differential diagnoses
  • Provide rationale for each differential diagnosis
• Final diagnosis
  • Pathophysiology of primary and rationale for choosing as final

Plan

• Medications
• Non-pharmacological recommendations
• Diagnostic tests
• Patient education
• Culture considerations
• Health promotion
• Referrals
• Follow up