Hi Debra,
I'm very sorry for this inconvenience I'm just trying to be a compliant with the Regualations here it the Progress Notes;
DOS:10/13/10
Chief Complaint(s):
midsternal chest pain
HPI:
General
Pt came in as a walk-in and will schedule a new appt next time. Her complaint is midsternal chest pain that last 6-8 minutes and comes and goes throughout the day. It happens with activity and at rest. She does not correlate it with happening more often after eating. There is no radiation of the pain. It is associated with nausea ans some SOB. She reports feeling acid in the back of her throat in the morning and feels like gagging. She has not taken anything OTC. She denies being on other meds. She reports drinking lots of coffee throughout the day.
Current Medication:
None
Medical History:
Allergies/Intolerance:
Gyn History:
OB History:
Surgical History:
Hospitalization:
Family History:
Social History:
ROS:
Objective:
Vitals:
HR 104, BP 125/80, RR 8, Temp 98.4, Ht 63, Wt 123, BMI 21.79
Past Results:
Examination:
General Examination
GENERAL APPEARANCE: well nourished and hydrated, NAD, comfortable, alert, female, young, pleasant. HEENT: normal, Head - NC/AT, tympanic membranes normal, eyes normal, EOMI bilaterally, PERRLA, clear conjuctiva, anicteric sclera. ORAL CAVITY: clear, mucosa moist, normal tongue. NECK: no thyroid abnormality, no mass, trachea midline. HEART: no murmurs, regular rate and rhythm,tachycardic. CHEST: normal shape and expansion, clear to auscultation, symmetrical. LUNGS: clear to auscultation bilaterally, no wheezes/rhonchi/rales. ABDOMEN: soft, NT/ND, BS present, no masses palpated, no hepatosplenomegaly. NEUROLOGIC EXAM: non-focal exam, alert and oriented x 3, CN's II-XII grossly intact, gait normal, normal strength, tone and reflexes, oriented x 3. Skin: Palpatation of skin and subcutaneous tissue:, Inspection of skin, normal, no rash, no ulcers. EXTREMITIES: no clubbing, no edema, no cyanosis. PERIPHERAL PULSES: normal (2+) bilaterally. LYMPH NODES: normal.
Physical Examination:
Assessment:
Assessment:
Chest pain, unspecified - 786.50 (Primary)
ROUTINE MEDICAL EXAM - V70.0
Plan:
Treatment:
Chest pain, unspecified
Start Omeprazole Capsule Delayed Release, 40 mg, Orally, 30, 1 capsule, Once a day, 30 day(s), Refills 3
Lab:LIPID PANEL Result Status : F HDL CHOLESTEROL 59 >=46 - mg/dL N
CHOLESTEROL,TOTAL 215 125-200 - mg/dL H
TRIGLYCERIDES 75 <150 - mg/dL N
LDL CHOL, CALCULATED 141 <130 - mg/dL H
CHOLESTEROL/HDL RATIO 3.6 < = 5.0 - N
Lab:CARDIO CRP Result Status : F CARDIO CRP 1.8 - mg/L N
Lab:THY PNL/TSH/FT4 Result Status : F TSH,3RD GENERATION 2.22 0.40-4.50 - mIU/L N
I feel pt has atypical chest pain most consistent with GERD. I am concerned about her tachycardia and she reports being anxious. I recommended she stop caffeine and she states that will not be a problem. I also told her if she does not get relief in a few days with omeprazole that she will need cardiology evaluation.
ROUTINE MEDICAL EXAM
Lab:COMP METAB PANEL W/EGFR Result Status : F ALT 16 6-40 - U/L N
ALBUMIN 4.5 3.6-5.1 - g/dL N
A/G RATIO 1.4 1.0-2.1 - N
AST 20 10-30 - U/L N
BILIRUBIN,TOTAL 0.4 0.2-1.2 - mg/dL N
CALCIUM 9.5 8.6-10.2 - mg/dL N
CARBON DIOXIDE 22 21-33 - mmol/L N
CHLORIDE 104 98-110 - mmol/L N
CREATININE 0.74 0.57-1.03 - mg/dL N
GLOBULIN,CALCULATED 3.3 2.2-3.9 - g/dL N
POTASSIUM 4.2 3.5-5.3 - mmol/L N
PROTEIN,TOTAL 7.8 6.2-8.3 - g/dL N
SODIUM 137 135-146 - mmol/L N
EGFR NON AFR AMERICAN >60 >=60 - mL/min/1.73m2 N
EGFR AFRICAN AMERICAN >60 >=60 - mL/min/1.73m2 N
GLUCOSE 87 65-139 - mg/dL N
UREA NITROGEN 8 7-25 - mg/dL N
BUN/CREATININE RATIO NOTE 6-22 - N
ALKALINE PHOSPHATASE 48 33-115 - U/L N
Lab:LIPID PANEL Result Status : F HDL CHOLESTEROL 59 >=46 - mg/dL N
CHOLESTEROL,TOTAL 215 125-200 - mg/dL H
TRIGLYCERIDES 75 <150 - mg/dL N
LDL CHOL, CALCULATED 141 <130 - mg/dL H
CHOLESTEROL/HDL RATIO 3.6 < = 5.0 - N
Lab: CBC (INCLUDES DIFF/PLT) Result Status : F DIFFERENTIAL An instrument differential was performed. - N
HEMATOCRIT 37.9 35.0-45.0 - % N
MONOCYTES,% 3.4 0-13 - % N
WBC 7.4 3.8-10.8 - Thous/mcL N
BASOPHILS,ABSOLUTE 22 0-200 - Cells/mcL N
BASOPHILS,% 0.3 0-2 - % N
EOSINOPHILS,ABSOLUTE 126 15-550 - Cells/mcL N
EOSINOPHILS,% 1.7 0-8 - % N
HEMOGLOBIN 12.8 11.7-15.5 - g/dL N
LYMPHOCYTES,ABSOLUTE 2316 850-3900 - Cells/mcL N
TOTAL LYMPHOCYTES,% 31.3 15-49 - % N
MONOCYTES,ABSOLUTE 252 200-950 - Cells/mcL N
NEUTROPHILS,ABSOLUTE 4684 1500-7800 - Cells/mcL N
TOTAL NEUTROPHILS,% 63.3 38-80 - % N
MPV 9.4 7.5-11.5 - fL N
PLATELET COUNT 222 140-400 - Thous/mcL N
MCH 27.9 27.0-33.0 - pg N
MCHC 33.8 32.0-36.0 - g/dL N
MCV 82.4 80.0-100.0 - fL N
RDW 13.8 11.0-15.0 - % N
RBC 4.60 3.80-5.10 - Mill/mcL N
Procedures:
Immunizations:
Diagnostic Imaging:
Lab Reports:
Preventive Medicine:
Next Appointment:
2 Weeks
Billing Information:
Visit Code:
99203 IM Office Visit New Pt Level 3. 1.)DX.786.59 2.)V70.0
Procedure Codes:
36415 VENIPUNCT, ROUTINE*. 1.)DX.786.59 2.)DX.V70.0
By the way we do only venipuncture in the clinic and sent to outside laboratory for the results.
THANK YOU VERY MUCH FOR YOUR KIND ATTENTION ON THIS MATTER..GOD BLESS
