Name: SpongeBob SquarePants

DOB: 07/01/1946

SUBJECTIVE: Pt. is here for follow up on his blood pressure management. He has been taking
his medication but he found that his blood pressure still elevated many times he takes it. He uses
wrist monitor at home. He has not have any headaches, dizziness, chest pain or shortness of
breath. Past medical history is remarkable for ongoing hypertension, hyperlipidemia and
diabetes.
HPI-ROS:

The patient is here for management of blood pressure.

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, very friendly, no acute distress or what so ever.
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no S3, S4, no murmurs, no rubs.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use
of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.

ASSESSMENT

PLAN

1. We reacived his blood pressure which today in the office is at 174/100. We retook it 2 or
3 times and remained elevated. He is not tachycardia with a pulse rate of 80. His current
regimen consists of amlodipine and lisinopril and at this point those are maxed out.
Amlodipine is 10 mg and lisinopril is 40 mg. So, we will add hydrochlorothiazide 25 mg
daisy to be taken with lisinopril. Monitor blood pressure reading at home 3 to 4 time per
week. He also is to follow up here in about 10-14 days. Let us know by telephone if there
are any questions, problems or if any blood pressure is not responding.
2. Laboratory: He has coming due next month. We ordered comprehensive metabolic panel,
CBC, urine microalbumin, hemoglobin A1C and fasting lipid panel. He may also follow
up here after his lab results as well in a month. My brother will see him in 10-14 days
first.

I, Hello Rache, MD, personally performed the services described in this documentation, as
scribed by Shayne Jessemae Almario, RN, in my presence, and it is both accurate and complete.
Name: Robert Smith
DOB: 08/14/1963

SUBJECTIVE: Pt. is here for follow up in his cholesterol, has been taking atorvastatin 10 mg a
day for the past year, and has not have any side effect from the medication at all. He has change
his lifestyle and diet enough that he wants to try cutting of the medication.
HPI-ROS:

The patient is here for follow up on his cholesterol.

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use
of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities:left knee is normal, left elbow shows pain to palpation and resisted supination and
pronation over the lateral epicondyle of left elbow, no obvious swelling seen, no erythema.
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.

ASSESSMENT

PLAN

1. His due for laboratory it’s been 1 year, he says he changed his lifestyle and loss weight
since last year. Discontinued atorvastatin for now. He can do laboratory in 1 month
consisting comprehensive metabolic panel and fasting lipid panel.
2. As to his right knee he has only occasional pain of it and is not debilitating whatsoever.
Left elbow does have some pain with gripping object and twisting things like screw
drivers, etc. but he was not finding it severe enough to cause him stop his activities. So,
reassurance given tend to avoid any twisting motion and very repetitive gripping and
pulling motion. When it flares up he can certainly put some ice on it or use over the
counter non-steroidal anti-inflammatory such as ibuprofen or naproxen.
3. Hopefully his laboratories when he come back with normal values and we can
discontinue atorvastatin at that time for the pending laboratories.

I, Hello Rache, MD, personally performed the services described in this documentation, as
scribed by Shayne Jessemae Almario, RN, in my presence, and it is both accurate and complete.
Name; Kevin Smith
DOB: 12/16/1955

SUBJECTIVE: Pt. is here for annual physical. Has no new complains, he’s not taking any
medication at all and feels quite well.
HPI-ROS:

The patient is here for annual physical.

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, and very friendly. Conversant and friendly affect.
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use
of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.
Rectal: no suspicious lesion, no hemorrhoids and prostate feels to be normal size, texture and
non-tender.

ASSESSMENT: Annual physical. ICD 10code Z00.00

PLAN

1. Comprehensive metabolic panel, CBC with deferential, urinalysis complete with reflux
culture and sensitivity, PSA.
2. Encourage him to call us 2 or 3 days after laboratory test are done.
3. He has encourage to get annual eye exam.
4. He has never had a screening colonoscopy. So, a referral for consult for screening
colonoscopy is given for Gastroenterology.
5. Continue healthy lifestyle and diet as well as regular exercise. May follow up annually or
soon or PRN

I, Hello Rache, MD, personally performed the services described in this documentation, as
scribed by Shayne Jessemae Almario, RN, in my presence, and it is both accurate and complete.
Name: Harry Jones
DOB: 12/25/1951

SUBJECTIVE: Pt. is here for follow up on Hypertension, Hyperlipidemia, as well as Coronary

Artery Disease and Diabetes. His blood sugar has been elevated in the morning running about
250-280. He has been also occasional exertional chest pain with concomitant shortness of breath.
He has not have swelling on his legs. He has not have any fever or chills. He denies any cough
though he continues to smoke. He also been struggling to lose weight his currently in 322
pounds.
HPI-ROS:

The patient is here for follow up on multiple medical health issues.

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: Exertional chest pain.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, and oriented. He does ambulate on his own but it is slow due to his
morbid obesity. He was able to transition from sit to standing position and vice versa without
assistance.
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Few scattered skin tag as well.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, and no
use of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.

ASSESSMENT

PLAN

1. We discuss his diabetes and currently his blood sugar is running above 200 in the
morning and we told his we need to increase dose of glipizide to 2 tablets twice a day 2.5
mg tablet twice a day. He need to continue checking his blood sugar fasting as well as 1-2
hours post prandial and report what are the sugar reading for the nest 10-14 days. For his
blood pressure goes continue on his amlodipine but we are going to decrease the dosage
to 5 mg from 10 mg as he may be getting some edema in his legs due to high dose of
amlodipine otherwise we will increase his lisinopril from 20 mg to 40 mg to hopefully
keep his blood pressure under good control. He is due for A1C testing as well as
chemistry panel and lipid testing in the next couple of months. He is also behind his urine
microalbumin testing as well. So laboratory slip given for next month for comprehensive
metabolic panel, fasting lipid panel, hemoglobin A1C, and urine microalbumin. He is to
follow up here after those test are done in the meantime he can leave me a message at the
front desk of his glucose logs so we can let him know if any further adjustments are
needed on his diabetic medications. Also stressed the importance of annual dialted eye
 exam for his diabetes. He won’t be due for that until this coming June. He understand all
that we discuss.

I, Hello Rache, MD, personally performed the services described in this documentation, as
scribed by Shayne Jessemae Almario, RN, in my presence, and it is both accurate and complete.