PROGRESS NOTE

PROVIDER NAME: SYDNEY DOWELL, A.P.R.N.

PATIENT: ROBERT BEYER

DATE OF BIRTH: 10/06/1964
DATE OF EVALUATION: 12/31/2020
PLACE OF EVALUATION: Office

HISTORY OF PRESENT ILLNESS: Dry cough for three days. He did have
temperature of 99.9 and chills on the first day, none since. No loss of taste or smell. No
known COVID exposure. He would like to have prescription for Z-Pak, which has
worked well for him. Also needs refill of atorvastatin.

MEDICAL (GENERAL) HISTORY

ALLERGIES: Reviewed.
PAST MEDICAL HISTORY: Reviewed.
IMMUNIZATIONS: Reviewed.
SOCIAL HISTORY: Reviewed.
FAMILY HISTORY: Reviewed.

REVIEW OF SYSTEMS:

GENERAL: No fever, chills.

CARDIOVASCULAR: No chest pain.

RESPIRATORY: No difficulty breathing.

GI: No abdominal pain, nausea, vomiting.

GU: No difficulty urinating.

INTEGUMENTARY: No rash.

PSYCHIATRIC: No depression.

PHYSICAL EXAMINATION:

VITAL SIGNS: ______

GENERAL APPEARANCE: Well developed, well nourished, and cooperative.

No acute distress.

HEENT: Head normocephalic. Conjunctiva, sclera, and lids

unremarkable.
PROVIDER NAME: SYDNEY DOWELL, A.P.R.N. Page 2

PATIENT: ROBERT BEYER

DATE OF BIRTH: 10/06/1964
DATE OF EVALUATION: 12/31/2020
PLACE OF EVALUATION: Office

CARDIOVASCULAR: Heart regular, rate and rhythm. Normal S1 and S2,

No edema.

RESPIRATORY: Respiratory effort unremarkable. Respiratory rate

and pattern normal. Lungs clear to auscultation .

MUSCULOSKELETAL: Normal gait.

INTEGUMENTARY: Skin warm and dry.

PSYCHIATRIC: Alert and oriented to person, place, time, mood, and

affect appropriate for situation. Judgment and
insight normal. Normal attention and concentration.

ASSESSMENT:
1. URI (upper respiratory infection).
2. Encounter for screening for COVID-19.
3. Mixed hyperlipidemia.
4. Medication refill.
5. Encounter for long-term current use of medication.
6. Vitamin D deficiency.

PLAN: He will goal to another facility for COVID testing. Advised quarantine until
negative results. Z-Pak given. To go to ER for any difficulty breathing. Reviewed labs
from 09/24/2020. Total cholesterol good at 138, HDL 48, triglycerides 51, LDL 77.
CMP: Glucose 101, A1c normal. TSH, CBC, and PSA are all normal. Vitamin D low at
20. He has followup appointment with Dr. Suresh Nair for 03/24/2021. Call if any new or
worsening symptoms.

PROVIDER NAME: SYDNEY DOWELL, A.P.R.N.

DICTATED AND CONFIRMED.

SD/bm

99214-95

J06.9, z11.52, e78.2, z76.0, z79.899, e55.9