Date and Time of Patient Visit: 11 / 9 / 2011 3:00 PM Name: OMMITED DOB: 1/2/1977 Source of Information: Patient Reliability

y of Source: Reliable Chief Complaint: I need a new doctor. History of Present Illness: Allison Henderson is a 34 year old Caucasian female with a history of hypertension and tobacco abuse who presents as a new patient as she has recently moved. Past Medical History: Hypertension o Diagnosed at age 31 (three years ago) o Controlled with Hydracortothiazide (see below) o States she eats a healthy diet Hospitalizations o Tubectomy (see below) o Childbirth No known history of CAD, MI, CVA, or cancer Medications:
Hydrochlorothiazide, Exact dosage not determined, 1 pill, PO daily

Calcium, dosage not determined, 1 pill, PO daily

Allergies: Penecillin Dust No other known food, drug, or environmental allergies Past Surgical History: Tubectomy o Age 29, patient did not want any more children, no complications, exact date not determined Past Obstetric/Gynecological History: Menses at 16 G1P1 vaginal, no complications Psychiatric History: No hx of personality disorders, depression, anxiety disorder, or suicide attempts Family History: Grandparents No known information Father Alive, 70. HTN dx age not determined Mother Deceased at 68, MI.

Sister Alive, HTN dx age not determined Husband Alive, 36 Daughter Alive, 14 No significant genetic disorders in family

Social History: Tobacco: 1 ppd starting at 18 16 pack years Alcohol: 2-4 glasses of wine per week Illicit Drugs: Denies past or current use Sexual History o Monogamous with husband o Does not feel at risk for HIV or other sexually transmitted diseases Occupation: Works at Macys Safety: Has CO and Smoke detectors in home, wears seatbelts Highest Level of Education: Community College Religion: Catholic Finances: Stable. No difficulty affording medications or living expenses. Diet: See HPI Marital Status: Married Military: No history of service Routine Health Maintenance & Immunizations: Last Comprehensive Physical 1 year ago by previous Primary Care physician Vision1 year ago by previous Primary Care physician Hearing 1 year ago by previous Primary Care physician Gynecological, including Pap Smear 1 year ago by previous Primary Care physician Cholesterol, 1 year ago by previous Primary Care physician Patient states she is up to date on her immunizations Advanced Directives & Healthcare Proxy: Healthcare Proxy: Husband No Advanced Directives Review of Systems: General: Patient denies recent weight changes, fever, weakness Head: Denies headache, dizziness, lightheadedness Eyes: Denies changes in vision, blurry vision, spots, double vision Ears: Denies ringing, pain, deafness, vertigo Nose: Denies frequent colds, stuffiness, congestion, nosebleeds Throat: Denies dryness, soreness, hoarseness Neck: Denies lumps, pain, stiffness Respiratory: Denies cough, shortness of breath, wheezing Cardiovascular: Denies pain, tightness, palpitations Gastrointestinal: Denies nausea, vomiting, diarrhea Genitourinary: Denies incontinence, bleeding, pain on urination Peripheral Vascular: Denies history of clots, cramps, color changes in fingertips or toes in cold
weather

Psychiatric: Denies nervousness, depression, anxiousness Hematological: Denies anemia, ease of bruising or bleeding, clotting issues, transfusions Endocrine: Denies hot or cold sensitivity, changes in thirst or hunger, changes in glove or shoes size

Physical Examination: [NOT CONDUCTED BY STUDENT THESE REPRESENT NORMAL FINDINGS] Vital Signs: [IN OSCE EXAM]Weight, Height, BMI, Temperature, BP, HR, RR General Survey: Caucasian female in no acute distress, appears older than stated age, dressed appropriately for weather, well groomed. She is alert, pleasant, and sitting comfortably. Skin: o Inspection: No acute rashes or redness noted, no petechiae or bruising, nails without pitting, clubbing, or cyanosis. o Palpation: Palms warm, no tenderness or crepitence Head o Inspection: Atraumatic and normocephalic, scalp without lesions o Palpation: Hair of average texture, non-tender Eyes o Inspection: Conjunctiva WNL, sclera white, no external or internal eye lesions o Vision 20/20 o Visual fields intact bilaterally by confrontation o Extra-occular eye movements bilaterally (EOMI B/L) o PERRLA o Fundoscopic exam shows disc margins are sharp, no papilledema noted or increased vasculature, no hemorrhages or exudates noted Ears o Inspection: External ears without lesions TM intact bilateraly, positive visualization of cone light and bondy landmarks o Palpation: Non-tender, no masses noted o Special Tests: Whisper test WNL Nose o Inspection: Muscose pink, septum midline, no deformity, no polyps o Palpation: Non-tender, no masses noted Throat o Inspection: Oral mucosea: Pink, no lesions noted, tonsils present, pharynx without exudates o Dentition: Good o No malodor o Palpation: No tenderness or masses noted Neck o Inspection: No redness or masses, no jugular vein distention noted o Palpation: Supple, no cervical lymphadenopathy, no anterior or posterior chain lymphadenopathy, thyroid midline without masses or nodules, trachea midline o ROM: WNL o Ascultation: No carotid for bruits Lymph Nodes o Inspection: No submandibular, supraclavicular, axillary, or inguinal masses or redness o Palpation: No submandibular, supraclavicular, axillary, or inguinal masses palpated Chest

o Inspection: Thorax symmetric with good excursion, no deformities o Palpation: No tenderness, tactile fremitus equal bilaterally o Percussion: Resonant is all lung fields, diaphragm excursion is 6cm B/L o Ascultation: CTAB no rales, rhonchi, crackles, or wheezing Breasts o Inspection: Symmetric, no redness, masses, dimpling, flatness or discharge o Palpation: No tenderness, no masses to palpation bilaterally Heart o Inspection: No jugular venous distention, no deformity, no visible apical heave or parasternal lift. o Palpaton: PMI in 4th intercostal space in the midclavicular line, no palpable heave, lift, rubs, or gallops appreciated o Ascultation: Heart has a regular rhythm and rate (RRR), S1S2 present, no murmurs, rubs, or gallops appreciated Abdomen o Inspection: Flat, no striae or dilated veins noted o Ascultation: +BS in all 4 quadrants, (bruits covered in peripheral vascular) o Palpation: Soft, non-tender, no rebound rigidity or guarding noted, no masses or hepatosplenomegaly noted o Percussion: No enlarged organs noted, tympanic over gas-filled areas, dull over solid organs, gas pattern normal, no ascites Genetalia: Not done Recta o Inspection: Sacrococcygeal and oerianal areas without lumps, ulcers, inflammation, rashes or excoriations o Palpation: no abnormal areas, no lumps or tenderness. Anus and rectum have no lesions. Sphincter tone normal, no tenderness, induration or irregularities noted. Rectal surface smooth without nodules, irregularities or induration o Special Tests: Hemocult SENSA performed and sent to lab Musculoskeletal & Structural (OMM) o Inspection: No somatic dysfunction found o Palpation: No tenderness, hypertonicity, or fibrosis noted o ROM (Active, passive): WNL o Strength: See Neuro o Sensation: See Neuro o Vascular: See Neuro Neurological o Awake, alert, oriented o Cranial Nerves: CN 2-12 intact bilaterally o Motor: Muscle strength is +5/5 at the trunk, proximal and distal musculature of the upper and lower extremities B/L o Cerebellar: Negative Rhomberg, negative pronator drift, rapid alternating movement WNL, finger to nose test WNL, heel to shin test WNL, gaint WNL no ataxia noted, fluid, normal heel and toe walking o Deep Tendon Reflexes: +2/4 at biceps, patellar, and Achilles o Behavior and Cognition: Awake and alert, responding appropriately Extremities

Warm. No edema or cyanosis of the upper or lower extremeties B/L. Calves supple and nontender bilaterally Peripheral Vascular o Pulses +2/4 at te radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries bilaterally. No carotid, emoral, iliac, renal, or aortic bruits appreciated

Diagnostic Studies: [NOT CONDUCTED BY STUDENT THESE REPRESENT NORMAL PROCEDURES] Hemocult Pap Smear Assessment and Plan: No acute problems apparent from history HTN Controlled (?) o Continue Hydracortothiazide, 25 mg, PO, daily o Recommend AHA/low salt o Discuss exercise plan, 30-60 minutes per day o Discuss Home BP monitoring and log o Follow up in one month to check log o Reduce Calcium due to Hydracortothiazide interaction Advanced Directives o Arrange for advanced directive paperwork and plan Health Maintenance o Verify Influenza vaccine and administer if needed o Verify last Tetanus vaccine and administer if needed o Take lipid panel. Pt at increased risk because of HTN. Rx for fasting profile for 1 week. Follow up after results return. o Schedule or perform Ophthalmology exam, last over 1 year ago o Schedule or perform Pelvic exam, last over 1 year ago o Schedule or perform Hearing exam, last over 1 year ago o Schedule Dental exam, last over 1 year ago o Encourage and explain the need for self breast exams o Schedule next routine physical in one year. Tobacco Use Uncontrolled o Discuss plans for quitting, provide reading material and explain risks including DEATH o Perform Pulmonary Function tests including peak flow, PEV/FEV ratios Obtain past medical records from previous doctor and have patient sign release forms Additional Questions to Ask and Facts to Verify o Hydrochlorothiazide dosing o Calcium supplement dosing o Ask about sexual function, past sexual partners, gender preferences for sex, birth control, safe sex practices o Sisters age o Age of onset for family illnesses (I.E. fathers HTN) o For next time: Remember Neurological, Breast, and Musculoskeletal ROS o Ask about allergy reactions (E.X. Does Penicillin causes Rash?) o Determine exact date of tubectomy and date of childbirth o Ask about caffeine, hobbies, and duration of marriage