Mona is for a 3 month follow up on her chronic conditions.She has no other complaints. No SOB, CP, dizziness, or dry mouth.GENERAL: The patient is...

Question 1. Mona is for a 3 month follow up on her chronic conditions. Shehas no other complaints. No SOB, CP, dizziness, or dry mouth. GENERAL: The patient is awake, alert, and communicative, in no acute distress. HEENT: Nose and throat are clear. NECK: Supple. LUNGS: Clear to auscultation. No rales, rhonchi, wheezes, or egophony. HEART: S1, S2, without murmur or gallop. ABDOMEN: Soft. EXTREMITIES: No edemaAssessment and Plan: Hyperlipidemia: Under excellent control, let us plan to back off the atorvastatin to thrice weekly. Would plan to check back on labs around 6 months.Hypertension: Stable, will continue losartan as is under good control. Follow-up: 6 months for labs, 1 year for office. 2021 EM Level2. George is in today for follow-up of being in the hospital with pneumonia and needs to go through his medication. He has finished his antibiotic and is feeling well. He missed a few of his medication dosage when he first got home but is doing much better now. Exam:Cardiovascular: Normal rate and regular rhythm. Pulmonary/Chest: No respiratory distress. Musculoskeletal: Left hand: She exhibits tenderness (left index at area of the PIP joint ) and swelling. She exhibits normal range of motion and normal capillary refill. Neurological: She is alert.Assessment and Plan: ADD:Symptoms stable. Taking Dexadrine 10mg twice daily. Tolerating well. When taking meds, focus is improved. Patient denies abdominal pain, loss of appetite, unexplained weight loss.HTN: BP stable. Taking Lisinopril 5mg daily and HCTZ 25mg daily. Tolerating well. Taking a potassium supplement daily as well. Denies LE edema. Discussed low sodium diet. Depression: Taking Zoloft 50mg daily. Tolerating well. Moods stable. Denies depression presently.Iron deficiency Anemia: Stable, Taking Iron supplement daily. 2021 EM Level3. Julie is in for her DM. Her daily sugars have been running high and she thinks she might need a change in her medication. She has no eye issues, excessive thirst, or excessive frequency of urination. Exam: BP 138/82 mmHg | Pulse 112 | Temp(Src) 36.7 °C (98 °F) (Temporal) | Resp 20 | Ht 1.753 m (5′ 9″) | Wt 102.059 kg (225 lb) | BMI 33.21 kg/m2RRR – normal Lungs – clear to auscultationNeck – no lymphadenopathyExtremities – no edemaAssessment and Plan: Type 2 diabetes, still with hyperglycemia, and not in control-increase Toujeo to 18 units once daily-Continue Metformin increase to 2000 mg twice daily. 2021 EM Level4. Susie is in today with complaints of ear pain for the last 2 days and just has been achy. No fever or throat pain. Exam:GENERAL: The patient is awake, alert, and communicative, in no acute distress. HEENT: Nose and throat are clear. NECK: Supple. LUNGS: Clear to auscultation. No rales, rhonchi, wheezes, or egophony. HEART: S1, S2, without murmur or gallop. Assessment and Plan: Strep test negative Otitis Media with no perforation of the ear drum. Amoxicillin 3 times a day for 7 days. 2021 EM Level5. Josh was in for follow up of his depression and doesn’t feel like he is at goal and wonders if he needs to adjust his medication. Exam: GENERAL: The patient is awake, alert, and communicative, in no acute distress. HEENT: Nose and throat are clear. NECK: Supple. LUNGS: Clear to auscultation. No rales, rhonchi, wheezes, or egophony. HEART: S1, S2, without murmur or gallop. Assessment and Plan: We will adjust Josh medication to 25mg of Buspar and have him come back in 1 month. I spent 40 minutes preparing chart, examination, and discussing the correct course of action for the depression. 2021 EM level6. Joe is in today for headache, fever, cough, and congestion. Worried he might have COVID. He still has his taste and smell and has no muscle pains. Exam: Right Ear: External ear normal. Left Ear: External ear normal. Bilateral TMs are dull. Post nasal drainage in pharynx; no exudate on tonsils. Pain and pressure in maxillary sinuses. Eyes: Conjunctivae are normal. Neck: Normal range of motion. Neck supple. Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Pulmonary/Chest: Effort normal and breath sounds normal. Lymphadenopathy: He has no cervical adenopathy. Neurological: He is alert and oriented to person, place, and time. Skin: Skin is warm. He is not diaphoreticAssessment and Plan: Pneumonia . COVID test and Strep test came back negative. Cefalexin x 3 for 10 days and also cough syrup for cough. 2021 EM Level Case Studies 1. CC. Debbie, who is a new patient, complains of vague symptoms of nausea and headaches and to establish care. Debbie presents with her mother. She has mild nausea and frontal headaches occasionally for the past 3 months. The family has recently moved from the East Coast. It gets worse at night when she lies down. No shortness of breath, fever, or chest painGeneral: Pleasant in NADHEENT: Eyes extraocular movements are intact. Pupils are reactive and TM’s are normal. Nose/Throat clear.Neck: No lymphadenopathyHeart: RRRLungs: Clear, no wheezes heardGastro: Soft, non-tender, no organomegaly or massesLabs: blood glucose obtained due to Fam HXResults: blood glucose level 315Assessment: Hyperglycemia, most likely diabetes considering strong family historyPlan: 45 minutes was spent with patient on exam and discussion with patient coming in for more blood to determine if she has hyperglycemia or diabetes. HPI Level: ______ 95Exam Level_____ MDM Level_______ E/M Level________________2.S: Establish patient presents with some pains in the neck, elbows, and lower back. The back pain has been present for just a few days and is slightly worse with movement. He has had pains in his elbows for approximately four months. It is relatively constant, no extreme. It does tend to hurt when he supinates his forearm fully. He has also had some mild pain in the back. He has no other significant history. Social: He is a nonsmoker. Family history: His father does have some mild arthritis and has hypertension and heart disease.O: HEENT: Tympanic membranes are clear bilaterally. Nose and throat are clear. Neck without lymphadenopathy. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft, flat, nontender, and nondistended. Bowel sound are active. He has some minimal tenderness in the right lower quadrant. Back: There is trigger-point tenderness. Lower extremities are normal to exam. He has negative straight leg raising in the supine position. A: Strain of the neck, elbows, and lower back. I think this may well be due to his work as a clerk. He spends a lot of time at a computer keyboard.P: He is to take the strain off his elbows and lower back by taking 5-minute breaks every 2 hours to stand and stretch. He is also to Methocarbamol twice a day as a muscle relaxer. HPI Level: _______ 95Exam Level_______ MDM Level____________ E/M Level_______3.S: This is a 78-year-old white female with multiple complaints. She has chronic sinusitis, esophagitis, fibromyalgia-type syndrome, and depression. She has had a great deal of postnasal drainage which gives her a sour feeling in her stomach. She also complains of recurrent problems with constipation, especially over the last three months. She has been using Correctol. This tends to give her runny stools for a day and then she has constipation again the next day. She has tried taking Colace. This was not helpful. Her depression is stable O: General: She is a well-nourished, well-developed, elderly white female in no acute distress. She appears somewhat sad and tearful. HEENT: Tympanic membranes were clear bilaterally. Nose had some pale mucosa, otherwise clear. She had tenderness along the left maxillary and left preauricular areas, and some mild temporomandibular joint tenderness. Throat was clear. Neck was supple. Lungs: Clear to auscultation. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft and diffusely tender to a mild degree. Bowel sounds were active. A: 1. Depression.2. Chronic sinusitis.3. Chronic Constipation.4. Esophagitis. P: 1. She has been off Zoloft for a while, so we will have her resume that. There is no record in the chart of her ever having an adverse reaction to it. 2. Beconase AQ 2 puffs b.i.d. 3. For her constipation, I recommended using Metamucil or some other type of similar fiber and increasing her fluid intake. She is going to make an appointment with Dr. Suess at his next opening, so that he can follow up on how she is doing with these changes. If she continues to have the sinus pain, we may need to refer her to an otolaryngologist. HPI Level: ______ 95Exam Level___________ MDM Level_ ________E/M Level________4.HISTORY AND PHYSICAL (Hospital)History of Present Illness: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of chest pain, weakness, malaise, and SOB on exertion for approximately one month. The pain is worse at night than the morning. The patient also reports a 15-pound weight loss. He denies fever, chills, and sweats, he denies eye issues, diarrhea, abd pain, or headaches, rest of the ROS is negative. Past Medical History: Essentially HTN and chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994. He is retired teacher and his grandmother had breast cancer. Medications: Lotensin once a day Allergies: No known drug allergies. Social History: He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as “very active.” Denies intravenous drug use. Physical Examination:General: This is a thin, black cachectic man speaking in full sentences with oxygen. Vital Signs: Blood pressure 96/56, heart rate 120. Temperature 101.6 degrees Fahrenheit. Respirations 30.HEENT: He has oral thrush, no conjunctivitis, eyes do have a yellow tint, TM are clear Chest: Bilateral basilar crackles, and egophony at the right and left middle lung fields. Heart: Regular rate and rhythm, no murmur, rub or gallop.Abdomen: Soft and nontender. Genitourinary: Normal. Skin: The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. He has very pale palms. Laboratory and X-Ray Data: Sodium 133, potassium 5.3, BUN 29, creatinine 1.8. Hemoglobin 14, white count 7100, platelet count 515. Total protein 10, albumin 3.1, AST 131, ALT 31. Urinalysis shows 1+ protein, trace blood. Total bilirubin 2.4, direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room air. Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates. Impression:1. Bilateral pneumonia: 2. Thrush.3. Hepatitis.4. Renal insufficiency.7. Subcutaneous nodules.8. Risky sexual behavior in 1982 in Haiti. Plan:1. Induced sputum rule out Pneumocystis carinii pneumonia and tuberculosis.2. Begin intravenous Bactrim and erythromycin.3. Begin prednisone.4. Oxygen.5. Nystatin swish and swallow.6. Dermatologic biopsy of lesions.7. Check HIV and RPR.8. Administer Pneumovax, tetanus shot and Heptavax if indicatedHPI Level: ______________ 95 Exam Level___________________ MDM Level_________________ E/M Level________________5. Patient is here for a nursing home follow-up. She has dementia, depression, HTN, DM, and gout. The conditions are stable, and she has been taking her medication regularly without complaint. She has no fever, SOB, chest pain, or abd pain. She has been going to the dinning room regularly and participating in daily activities. She is retired schoolteacher and both her parents died of cancer. General: She is a well-nourished, well-developed, elderly white female in no acute distress. She appears somewhat sad and tearful. HEENT: Tympanic membranes were clear bilaterally. Nose had some pale mucosa, otherwise clear. She had tenderness along the left maxillary and left preauricular areas, and some mild temporomandibular joint tenderness. Throat was clear. Neck was supple. Lungs: Clear to auscultation. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft and diffusely tender to a mild degree. Bowel sounds were activeContinue current medication for her chronic problems of dementia, depression, HTN, DM, and gout. We are going to increase her Wellbutrin to 3 times a day. HPI Level: ______________ 95 Exam Level___________________ MDM Level_________________ E/M Level________________ Health Science Science Nursing HIT MISC Share QuestionEmailCopy link Comments (0)