PROGRESS NOTE

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

PATIENT: KIM CRAIN

DATE OF BIRTH: 03/12/1961
DATE OF EVALUATION: 12/31/2020
PLACE OF EVALUATION: Office

HISTORY OF PRESENT ILLNESS: Green nasal drainage for one month, bilateral
earaches. No fever. She does have tinnitus for a long time, but it does get worse when she
has a respiratory infection. She has not been taking vitamin D or amlodipine for a couple
of months. She does have a blood pressure monitor, but she has not checked it. She
occasionally does have edema and at that time she will take furosemide and potassium
p.r.n. She does have joint pain at multiple sites. The Celebrex does help. She has fainted
when she gets her blood drawn so she does not like to have test done.

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

PATIENT: KIM CRAIN

DATE OF BIRTH: 03/12/1961
DATE OF EVALUATION: 12/31/2020
PLACE OF EVALUATION: Office

HEENT: Head normocephalic. Conjunctiva, sclera, and lids

unremarkable.

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. Sinusitis
2. Pain, joint, multiple sites
3. Vitamin D deficiency
4. HLD (hyperlipidemia)
5. Hypertension
6. Tinnitus
7. Edema
8. Medication refill
9. History of Barrett's esophagus
10. Encounter for long-term current use of medication
11. NPDx Abn react-blood sampling
12. Influenza vaccination declined
13. Pedal edema

PLAN: She will come in for labs on 01/06/2021. Notation written that she is to lie down
when she has her labs drawn. She brings someone with her to stay with her while it is
done. We will obtain CBC, CMP, TSH, lipids, vitamin D, PTH, rheumatoid panel, and
ANA. Amoxil given. Discussed medication administration, side effects, and risks.
Discontinue for any rash or itching. Recommended yogurt to prevent yeast. She declines
flu vaccine. Call if any problems. Phone visit total lasting 33 minutes.

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

DICTATED AND CONFIRMED.

SD/is/kk

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