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Clinical Documentation Template

Student Name and clinical course:  ______________________

ID:

Client’s Initials*: AB Age 25 Race White Gender Female Date of Birth 08/20/1995

Insurance Self Marital Status Single

The patient came to the clinic alone. She can be regarded to be a reliable historian, since none of the details she provided has any hint of inaccuracy. 

Subjective:

CC: Shortness of breath

HPI: AB, a 25 year old white female has presented to the clinic with shortness of breath. The patient has experienced this for the last three days, though the symptoms have intensified in the last one day. The patient is clearly overweight, with a body mass index of 32. The patient experiences the issue most when she does some physically exerting work, such as running up the stairs, and at night. By sitting upright, and after considerable rest, the issue subsides. In some instances, the issue is quite severe, and has led the patient to seek medical intervention. Though she has had the issue in the past, the current episodes seem to be more intense. 

ROS

Constitutional: The patient appears to be of sound constitution, though obese. 

Eyes: The patients eyes are of a normal color, with no hint of jaundice or bloodshot eyes. 

Ears/Nose/Mouth/Throat: All organs are okay, though the patient sometimes feels her nose is blocked. 

Cardiovascular: Faster heartbeat than normal

Pulmonary: The patient has symptoms consistent with pulmonary hypertension

Gastrointestinal: All appear normal, no reports or symptoms or unusual bowel movement or pain

Genitourinary: No unusual or abnormal issues reported

Musculoskeletal: No muscle or joint pain

Integumentary & breast: Mammogram returned normal results

Neurological: No issues reported

Psychiatric: Patient passed psychiatric exams

Endocrine: It appears normal

Hematologic/Lymphatic: normal plasma count, sufficient blood levels and flow. No signs to indicate anemia. 

Allergic/Immunologic: No allergies reported or observed. 

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Past Medical History:

• Medical problem list Previous issues of shortness of breath were not reported, since they were slight and passed without any medical intervention. 

• Preventative care: No preventive measures have been applied in the past. 

• Surgeries: None

• Hospitalizations: None in the past 

• LMP, pregnancy status, menopause, etc. for women. Pregnancy tests are negative. Gynecological exams are all okay. 

Allergies:

No allergies reported. 

Medications: The patient takes occasional pain killers. Besides this, she takes no other medication. 

Family History: The patient’s parents, and two brothers are also overweight, but none is clinically obese. The patient alludes to a dish predominantly made up of fried foods, and overly high in starch. This may be a reason for the patient’s obesity, as well as lack of sufficient physical exercise. 

Social History:

               -Sexual history and contraception/protection: the patient is in a stable relationship, They are not ready to have any children, so have been using contraceptives.

               -Chemical history (tobacco/alcohol/drugs): the patient claims to be a non-smoker, though she says her partner is a smoker.

Other: the patient’s diet consists of at least one fried item. Her work prevents her from having regular exercise. In addition, she spends most of the day sitting, since she is a cashier at a local store. She does not have a baby yet. Besides obesity, the patient appears to be otherwise healthy. 

Objective

Vital Signs:   HR 105 b/m     BP   130/84    Temp    35.6 RR  15/m     SpO2     94%    Pain  sporadic chest pains 

Height      87kg Weight      170 BMI    30 

Labs, radiology or other pertinent studies: 

Urinary test for pregnancy – negative (09/08/2020)

Physical Exam

All physical exam results are normal. 

Assessment

Differentials 

1. Pulmonary hypertension – due to the obesity and lack of exercise

2. Asthma – the patient appears to have asthma since many seem to be attacks rather than shortness of breath

3.Congestive heart failure – a comorbidity with obesity.

Diagnosis Pulmonary hypertension

Plan 

Diagnostics: Pulmonary hypertension

Treatment: A prescription of vasodilators Lisinopril/HCT 20/12.5 Daily #90, refills 3

Education: take up physical exercise, and reduce amount of fat in diet to tackle excess weight

Follow Up every fortnight