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History and Physical ( H and P ) Medical Transcription Transcribed Sample Report


REASON FOR ADMISSION:  The patient is a (XX)-year-old female who comes in to establish as a new patient.

PAST MEDICAL HISTORY:  Rheumatoid arthritis, seasonal allergies, dyslipidemia, hypertension and osteoarthritis.

PAST SURGICAL HISTORY:  She had a C-section in the remote past.

FAMILY HISTORY:  No history of coronary artery disease, heart attack, diabetes or strokes.  No history of cancers.  No history of arthritis.

SOCIAL HISTORY:  The patient is a nonsmoker, nonalcoholic.  Sexually transmitted disease:  None.  No use of recreational drugs.

MEDICATIONS:  Diovan 80 mg p.o. daily, meclizine 25 mg p.o. b.i.d. p.r.n. for dizziness, lovastatin 20 mg p.o. daily, cimetidine 400 mg p.o. b.i.d., Allegra 180 mg p.o. daily, Rhinocort Aqua spray 1 spray daily, fluocinolone cream 0.025% apply b.i.d. as needed topically, methylprednisolone 4 mg as directed, Patanol 0.1% 1 gtt in each eye b.i.d.


REVIEW OF SYSTEMS:  Positive left shoulder pain, 6/10 for the last one month.  Pain gets better with steroid medication.  She received a course of Medrol Dosepak before and she felt great.  The patient denies blurred vision.  No headaches.  No dizziness.  No palpitations.  No chest pain.  No shortness of breath.  No abdominal pain.  No nausea.  No vomiting.  No diarrhea.  No constipation.  No other joint pain.  No other pain all over the body.  No urinary symptoms.

VITAL SIGNS:  Blood pressure 162/72, repeat is 152/72; heart rate 66; respiratory rate 18; temperature 98.4.  Height is 5 feet 4 inches.  Weight is 146.  Pulse oximetry is 98%.
GENERAL:  The patient is well developed, well nourished, not in any acute distress.  Alert and oriented x3.
SKIN:  Dry and clear.
HEENT:  Eyes:  Pupils are equally reactive to light.  Fundi are clear.  The conjunctiva is clear and there is no sign of anemia.  Mouth:  Oral mucosa is pink and moist.  Tonsils are normal.
NECK:  Range of motion is intact.  Trachea is in the middle and there is no thyromegaly or lymphadenopathy.  No JVD and no carotid bruits.
LUNGS:  Clear bilaterally with no dullness to percussion.
HEART:  Regular, with no murmurs and no gallop.
ABDOMEN:  Benign, not tender, not distended.  No masses.  No hepatosplenomegaly.  Bowel sounds are normoactive.
EXTREMITIES:  She has no calf tenderness.  Her range of motion is intact, except passive range of motion is decreased in the left shoulder articulation because of the pain.  Most pain she gets in the left shoulder is when she abducts above head level her left arm.  Otherwise, the peripheral pulses are normal bilaterally.
NEUROLOGICAL:  Cranial nerves II through XII are intact.  There is no motor or sensory deficit.  Deep tendon reflexes are normal in all four extremities.

1.  Left shoulder pain.
2.  Uncontrolled hypertension.
3.  Dyslipidemia.
4.  Rheumatoid arthritis.
5.  Osteoarthritis.
6.  Seasonal allergies.

PLAN:  We will order rheumatoid factor and ESR.  Also, CPK, urinalysis, stool occult blood x3, comprehensive metabolic panel, lipid panel, CBC, vitamin B12 and folate level, hemoglobin A1c, and magnesium level.  We gave a tetanus shot, since the patient never had a tetanus shot.  Also, the patient was advised to come in a week or two to get the flu shot.  The patient already received the pneumonia shot, so we are going to defer on this vaccine.  We advised the patient to have a DEXA scan and screening bilateral mammogram.  We advised the patient to increase the dose of her Diovan; instead of 80 mg p.o. daily, she is going to start on Diovan 160 mg p.o. daily.  She is going to continue with her lovastatin 20 mg p.o. q.p.m.  The patient was advised to take the lovastatin with food.  The patient was prescribed the fluocinolone 0.025% cream to apply under her breasts as needed twice a day p.r.n. for atopic dermatitis.  The patient was prescribed Medrol Dosepak x1.  She was advised to return to the clinic next month for followup.  In the meantime, she was advised to follow a low-salt, low-fat, low-cholesterol diet with plenty of fluid intake and exercises for rheumatoid arthritis.  The patient was also advised to continue her other medications like cimetidine, Allegra, Rhinocort, and Patanol.  The patient was advised to call us as soon as possible with any problems.