SUBJECTIVE: NEW PATIENT HISTORY
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CHIEF COMPLAINT: initial visit to establish primary
care.
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HPI:
{FLD:ALLFT47/200}
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PMH (problem list):
|PROBLEM LIST- TAMPA|
H/O:
HTN {FLD:X BOX} YES {FLD:X BOX} NO
Cardiovascular Dz {FLD:X BOX} YES {FLD:X BOX} NO
TB/positive PPD
{FLD:X BOX} YES {FLD:X BOX} NO
PUD {FLD:X BOX} YES {FLD:X BOX} NO
Depression {FLD:X BOX} YES {FLD:X BOX} NO
Anxiety {FLD:X BOX} YES {FLD:X BOX} NO
PTSD {FLD:X BOX} YES {FLD:X BOX} NO
Hepatitis {FLD:X BOX} YES {FLD:X BOX} NO
Cancer {FLD:X BOX} YES {FLD:X BOX} NO
MOST RECENT TESTS:
Colonoscopy
- {FLD:X BOX} YES {FLD:X BOX} NO
Stress Test
- {FLD:X BOX} YES {FLD:X BOX} NO
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|DISABILITIES/SC (HS)|
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Medications:
|ACTIVE MEDS BY PT STATUS|
|REMOTE ACTIVE MEDICATIONS|
|EXPIRED OP MEDS;180|
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ALLERGY/ADVERSE REACTIONS, confirmed by
patient:|ALLERGIES/ADR|
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PAST SURGICAL Hx:
{FLD:ALLFT47/200}
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FAMILY HISTORY - Patient was asked about a family
history of:
Mother:{FLD:00 EDIT BOX 24}
Father:{FLD:00 EDIT BOX 24}
Siblings:{FLD:00 EDIT BOX 24}
=============================================================================
SOCIAL HISTORY:
Alcohol use: {FLD:00 YES/NO} {FLD:0-10 BOX} drinks {FLD:DAY/WK/MON} ADDITIONAL COMMENTS:{FLD:00 EDIT BOX 24}
Illicit (street) drugs used recently? {FLD:00
YES/NO} ADDITIONAL COMMENTS:{FLD:00 EDIT BOX 24}
Any IV Drug
use?
{FLD:00 YES/NO}
Last time illicit drugs used (if applicable)?
Type: {FLD:X BOX} Cannaboids {FLD:X BOX}
Cocaine {FLD:X BOX} Heroin
{FLD:X BOX}
Methadone {FLD:X BOX} Opiates
Tobacco use: {FLD:X
BOX} NEVER
Current:{FLD:SMOKE} {FLD:0-10
BOX} PP {FLD:DAY/WK/MON} Year Quit:{FLD:DATE}
Type - {FLD:X BOX} Cigarettes
{FLD:X BOX} Cigars {FLD:X BOX} Pipe {FLD:X BOX} Smokeless
Social status: {FLD:ALLMARTIALSTATUS4}
ADDITIONAL COMMENTS:{FLD:00 EDIT BOX 24}
Employment:{FLD:TBI/POLY VOCATIONAL
STATUS} Occupation: {FLD:00 EDIT BOX 24}
Living arrangements: {FLD:00 EDIT BOX 24}
Functional Status:{FLD:00
EDIT BOX 24}
Exercise type/frequency: {FLD:00 YES/NO} {FLD:0-10
BOX} times {FLD:DAY/WK/MON}
ADDITIONAL COMMENTS:{FLD:00
EDIT BOX 24}
MILITARY HISTORY:
BRANCH OF SERVICE: {FLD:X BOX}
Army {FLD:X BOX} Marines {FLD:X BOX}
Air Force
{FLD:X
BOX} Navy {FLD:X BOX} Coast Guard
Combat
veteran? {FLD:00 YES/NO}
Environmental Exposure: {FLD:00 YES/NO}
Duties/occupation: {FLD:00
EDIT BOX 24}
OUTSIDE RECORDS REVIEWED/AVAILABLE: {FLD:00 YES/NO}
PRIVATE PHYSICIAN(S): {FLD:00 YES/NO} {FLD:ADDITIONAL COMMENTS (TEXT)}{FLD:00 EDIT BOX 24}
DST Tool Reviewed:
{FLD:X BOX}Eligible {FLD:X BOX}Not Eligible
Patient's preference:
{FLD:X BOX}Opt-in for CC {FLD:X BOX}Opt-out for CC
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REVIEW OF SYSTEMS: per HPI
[x]yes
-----------------
Gen: {FLD:X BOX} fevers {FLD:X BOX} night sweats.
{FLD:X BOX} weight changes
Eyes: {FLD:X BOX} vision changes
Ears: {FLD:X BOX} hearing changes
Mouth: {FLD:X BOX} dysphagia
Pulm: {FLD:X BOX} dyspnea {FLD:X
BOX}PND {FLD:X BOX}cough
CV: {FLD:X BOX} chest pain {FLD:X
BOX}palpitations {FLD:X BOX}edema
GI: {FLD:X BOX} n/v/d {FLD:X
BOX}melena {FLD:X BOX}hematochezia
GU: {FLD:X BOX} dysuria. {FLD:X BOX}flank
pain {FLD:X BOX} hematuria
MSK: {FLD:X BOX} muscle pain {FLD:X BOX} joint pains
SKIn: {FLD:X BOX} new rashes
NEURO: {FLD:X BOX} numbnes
{FLD:X BOX} tingling {FLD:X BOX}focal weakness or
slurred speech {FLD:X BOX}headache
PSYCH: {FLD:X BOX}suicidal
ideations {FLD:X BOX}depression {FLD:X BOX}anxiety {FLD:X BOX}sleeping problem
=============================================================================
PHYSICAL EXAM:
VITALS (most recent, as listed in the electronic
record):
B/P:
|BLOOD PRESSURE|
Pulse: |PULSE|
RR: |RESPIRATION|
Temperature: |TEMPERATURE|
Height: |PATIENT HEIGHT|
BMI: |BMI|
Pain: |PAIN| (0-10 scale)
Weight history - Most recent three weights:
|WEIGHT HISTORY|
APPEARANCE: {FLD:X BOX}Well
Developed, well-nourished {FLD:X BOX}Obese
{FLD:X BOX}No acute distress
HEAD:
{FLD:X BOX}NC/AT
EYES:
{FLD:X BOX}PERRL {FLD:X BOX}EOMI {FLD:X BOX}no scleral icteric
NECK:
{FLD:X BOX}No masses palpable
{FLD:X BOX}No bruits appreciated
{FLD:X BOX}FROM
LUNGS:
{FLD:X BOX}CTA {FLD:X BOX}no wheezes {FLD:X BOX}no rhonchi
{FLD:X BOX}decreased breath sounds bilaterally
CARDIOVASCULAR:
RHYTHM: {FLD:X BOX}regular
{FLD:X BOX}normal s1 s2
AUSCULTATION: {FLD:X BOX}no
murmur appreciated {FLD:X BOX}murmur
ABDOMEN: {FLD:X BOX}soft
{FLD:X BOX}nontender
{FLD:X
BOX}normal bowel sounds
BACK: {FLD:X
BOX}non-tender spine {FLD:X BOX}full
range of motion
SKELETAL: {FLD:X BOX}shoulder
{FLD:X BOX}knee
LOWER EXTREMITIES: (indicated by "X")
Edema
- {FLD:X
BOX}YES {FLD:X BOX}NO
Cyanosis - {FLD:X BOX}YES {FLD:X BOX}NO
Pulses - {FLD:X BOX}2+ {FLD:X BOX}1+/trace
{FLD:X BOX}nonpalpable
Microfilament exam -{FLD:X
BOX}
SKIN: {FLD:X BOX}no rash
DRE: {FLD:X BOX}declines/defers
NEURO: {FLD:X BOX}no focal deficits {FLD:X BOX}good muscle bulk/tone
PSYCH: {FLD:X BOX}normal
mood and affect {FLD:X BOX}calm and cooperative
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LABS:
-----
|CBC (2 OCC)|
|BMP/1 OCC 30D (HS)|
|HEPATIC PANEL/1 OCC 3M (HS)|
|HGBA1C 2OCC 1YR (HS)|
|LIPID CLINIC (HS)|
|PSA(HS)|
{FLD:X BOX} no recent or new labs to discuss today
{FLD:X BOX} lab results discussed with patient today
{FLD:X BOX} labs drawn results pending
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ASSESSMENT/PLAN:
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FOLLOW UP: [
] week(s) [ ] month(s) & RTC P.R.N. with
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Immunizations: |IMMUNIZATIONS (HS)|