jlb102780
Guru
Hi everyone 
I'm in need of a second opinion on the HPI in the report below. I am only finding it meets an Expanded Problem Focused and was wanting some additional brains to look at this with me. This is a new patient office visit.
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History - Expanded Problem Focused, Level 2
HPI=2 - Brief, Documented status of 2 conditions (Mild Mitral Insufficiency, Well controlled HTN)
ROS=5 - Complete, 10+ documented
PFSH=5 - Complete, Past Medical, Family and Social Histories documented
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REASON FOR VISIT:
This 66 year old female presents for heart murmur.
HISTORY OF PRESENT ILLNESS:
1. heart murmur
The patient recently moved here from Maryland. She was being followed by a cardiologist for a congenital heart murmur and wants to establish with someone here in FL.
2. general
She has had no chest discomfort suggestive of ischemia. The patient denies orthopnea, PND, DOE, or edema. Ms. Mahaffey has not had palpitations, syncope or near syncope. She denies claudication. There is no discoloration or ulceration of the lower extremities. She has had no TIA or stroke-like symptoms. The patient has no symptoms attributable to valvular heart disease.
CARDIAC HISTORY
VALVULAR:
1 AR
2 MR
RISK FACTORS:
1 Hypertension
2 Dyslipidemia [Type: Hyperlipidemia]
CARDIOVASCULAR PROCEDURES
ELECTROPHYSIOLOGY:
EKG (Sinus Rhythm, 52 bpm) - 2/20/2014
ALLERGIES/INTOLERANCES:
NO KNOWN ALLERGIES
PAST MEDICAL/SURGICAL HISTORY (Detailed)
cosmetic surgery
Dermatitis
Diverculitis
Onychomycosis, Toenail
FAMILY HISTORY (Detailed)
Family history of Cancer, unknown
dn 09/11/2014 - Basal Cell Carcinoma, Skin
SOCIAL HISTORY (Detailed)
Preferred language is English.
MARITAL STATUS/FAMILY/SOCIAL SUPPORT
Currently single.
Does not have children.
CAFFEINE
The patient uses caffeine.
LIFESTYLE
Regularly.
REVIEW OF SYSTEMS:
CONST - Negative for weight gain, fever. Positive for weight loss. EYES - Positive for visual changes. ENT - Negative for hearing loss. RESP - Negative for snoring, hemoptysis, dyspnea. CARD - Negative for chest pain, diaphoresis, orthopnea, palpitation, syncope, PND. VASC - Negative for claudication, edema. GI - Negative for nausea, reflux, bleeding. GU - Negative for hematuria, nocturia. REPROD - Positive for Hx of OCP. ENDO - Negative for goiter, tremors. NEURO - Negative for dizziness, memory loss, seizures. PSYCH - Negative for depression, hallucinations. DERM - Negative for rash, skin sores. M/S - Negative for joint pain, myalgia. HEMAT - Negative for acute anemia, thrombocytopenia.
VITAL SIGNS
BP mm/Hg 110/72
Pulse/min 74
Height (Total in.) 68.00
Weight (lbs.) 185.00
BMI 28.13
PHYSICAL EXAM:
Const Neg Nourishment - Well Nourished. Appearance - Well Developed.
Eyes Neg Lids/External - Bilateral Normal. Conjunctiva - Bilateral Normal.
NMT Neg Oral Mucosa - Moist, No Cyanosis, No Pallor.
Neck Neg JVP - Less Than 8.
Resp Neg Respirations - Nonlabored. Breath Sounds - Clear Throughout. Rales - Absent. Wheezes - Absent. Rhonchi - Absent.
Cardiac Neg Rhythm - Regular. Palpation - PMI Normal. Heart Sounds - S1 Normal, S2 Normal, No S3, No S4.
Cardiac Pos Murmurs - I/VI systolic ejection murmur heard at the base; II/VI holosystolic murmur heard at the apex.
Vasc Neg Carotid - Bilateral Normal Pulse. Aorta - Normal Size. Femoral - Bilateral Normal Pulse. Posterior Tibial - Bilateral Normal Pulse.
Abd Neg Tenderness - None. Hepatomegaly - Absent. Splenomegaly - Absent.
Skin Neg Venous Stasis Ulcer - Absent.
M/S Neg Gait - Normal. Able to Exercise - Yes.
EXT Neg Clubbing - Absent. Lower Extremity Edema - Absent.
Psych Neg Orientation - Oriented to Time, Person, Place. Mood - Appropriate.
IMPRESSION AND PLAN
01. Aortic regurgitation: EKG performed - ordered and reviewed by me today. It shows NSR, LAE
02. Mitral regurgitation: Tests reviewed with patient. Echocardiography demonstrates mild mitral insufficiency.
03. Mixed hyperlipidemia: Managed by: PCP.
04. Hypertension: Well controlled on medical therapy. We will continue the current therapy.
ORDERS:
1 Return office visit with XX MD in 1 Year.
FINAL MEDICATION LIST
Sig Description
atorvastatin 20 mg tablet - take 1 tablet by oral route every day
lisinopril 20 mg tablet - take 1 (20MG) by oral route every day at bedtime
I'm in need of a second opinion on the HPI in the report below. I am only finding it meets an Expanded Problem Focused and was wanting some additional brains to look at this with me. This is a new patient office visit. ----------------------------------------------------------------------------------------------------------------------------------------------------
History - Expanded Problem Focused, Level 2
HPI=2 - Brief, Documented status of 2 conditions (Mild Mitral Insufficiency, Well controlled HTN)
ROS=5 - Complete, 10+ documented
PFSH=5 - Complete, Past Medical, Family and Social Histories documented
----------------------------------------------------------------------------------------------------------------------------------------------------
REASON FOR VISIT:
This 66 year old female presents for heart murmur.
HISTORY OF PRESENT ILLNESS:
1. heart murmur
The patient recently moved here from Maryland. She was being followed by a cardiologist for a congenital heart murmur and wants to establish with someone here in FL.
2. general
She has had no chest discomfort suggestive of ischemia. The patient denies orthopnea, PND, DOE, or edema. Ms. Mahaffey has not had palpitations, syncope or near syncope. She denies claudication. There is no discoloration or ulceration of the lower extremities. She has had no TIA or stroke-like symptoms. The patient has no symptoms attributable to valvular heart disease.
CARDIAC HISTORY
VALVULAR:
1 AR
2 MR
RISK FACTORS:
1 Hypertension
2 Dyslipidemia [Type: Hyperlipidemia]
CARDIOVASCULAR PROCEDURES
ELECTROPHYSIOLOGY:
EKG (Sinus Rhythm, 52 bpm) - 2/20/2014
ALLERGIES/INTOLERANCES:
NO KNOWN ALLERGIES
PAST MEDICAL/SURGICAL HISTORY (Detailed)
cosmetic surgery
Dermatitis
Diverculitis
Onychomycosis, Toenail
FAMILY HISTORY (Detailed)
Family history of Cancer, unknown
dn 09/11/2014 - Basal Cell Carcinoma, Skin
SOCIAL HISTORY (Detailed)
Preferred language is English.
MARITAL STATUS/FAMILY/SOCIAL SUPPORT
Currently single.
Does not have children.
CAFFEINE
The patient uses caffeine.
LIFESTYLE
Regularly.
REVIEW OF SYSTEMS:
CONST - Negative for weight gain, fever. Positive for weight loss. EYES - Positive for visual changes. ENT - Negative for hearing loss. RESP - Negative for snoring, hemoptysis, dyspnea. CARD - Negative for chest pain, diaphoresis, orthopnea, palpitation, syncope, PND. VASC - Negative for claudication, edema. GI - Negative for nausea, reflux, bleeding. GU - Negative for hematuria, nocturia. REPROD - Positive for Hx of OCP. ENDO - Negative for goiter, tremors. NEURO - Negative for dizziness, memory loss, seizures. PSYCH - Negative for depression, hallucinations. DERM - Negative for rash, skin sores. M/S - Negative for joint pain, myalgia. HEMAT - Negative for acute anemia, thrombocytopenia.
VITAL SIGNS
BP mm/Hg 110/72
Pulse/min 74
Height (Total in.) 68.00
Weight (lbs.) 185.00
BMI 28.13
PHYSICAL EXAM:
Const Neg Nourishment - Well Nourished. Appearance - Well Developed.
Eyes Neg Lids/External - Bilateral Normal. Conjunctiva - Bilateral Normal.
NMT Neg Oral Mucosa - Moist, No Cyanosis, No Pallor.
Neck Neg JVP - Less Than 8.
Resp Neg Respirations - Nonlabored. Breath Sounds - Clear Throughout. Rales - Absent. Wheezes - Absent. Rhonchi - Absent.
Cardiac Neg Rhythm - Regular. Palpation - PMI Normal. Heart Sounds - S1 Normal, S2 Normal, No S3, No S4.
Cardiac Pos Murmurs - I/VI systolic ejection murmur heard at the base; II/VI holosystolic murmur heard at the apex.
Vasc Neg Carotid - Bilateral Normal Pulse. Aorta - Normal Size. Femoral - Bilateral Normal Pulse. Posterior Tibial - Bilateral Normal Pulse.
Abd Neg Tenderness - None. Hepatomegaly - Absent. Splenomegaly - Absent.
Skin Neg Venous Stasis Ulcer - Absent.
M/S Neg Gait - Normal. Able to Exercise - Yes.
EXT Neg Clubbing - Absent. Lower Extremity Edema - Absent.
Psych Neg Orientation - Oriented to Time, Person, Place. Mood - Appropriate.
IMPRESSION AND PLAN
01. Aortic regurgitation: EKG performed - ordered and reviewed by me today. It shows NSR, LAE
02. Mitral regurgitation: Tests reviewed with patient. Echocardiography demonstrates mild mitral insufficiency.
03. Mixed hyperlipidemia: Managed by: PCP.
04. Hypertension: Well controlled on medical therapy. We will continue the current therapy.
ORDERS:
1 Return office visit with XX MD in 1 Year.
FINAL MEDICATION LIST
Sig Description
atorvastatin 20 mg tablet - take 1 tablet by oral route every day
lisinopril 20 mg tablet - take 1 (20MG) by oral route every day at bedtime