Progress Sheet

2 Apr

NAME: XXXXXXXX, XXLXX
DOB: 07/01/1969
Nkda

Notes and Consultation

04/02/2007

Patient presented with depression, suicidal tendencies, SOB, dry mouth, coughing, wheezing, fatigue, insomnia (16 years running), auditory illusions, possible signs of schizophrenia or bi-polar disease.

Vital signs:
Weight: 216 lbs.
Blood pressure: 128/78
Pulse: 59
Respiratory rate: 18
Temperature: 97.9

Review of systems: Constitutional: WNL, Eyes: WNL, ENT: sore throat, nasal congestion, Pulmonary: SOB, coughing, wheezing, CVS: chest pain, palpitations, GIS: faint abdominal pain, GERD, GUS: WNL, Muscular/skeletal: no sign of osteoarthritic changes, Skin: WNL, Neurological: fatigue, anxiety, hallucinations, insomnia.

P.E.: Head: NC/AT. Point tenderness over frontal and ethmoidal sinuses
Eyes: WNL
ENT: pharyngeal congestion without exudates.
Neck: supple, JVD present, no thyromegaly, no lymph adenopathy
Lung: bilateral Rolls Ronhai moderate to severe inspiratory and expiratory wheezing, bi-basilar crepitants.
CVS: S1S2 present, heart RRR, 2/6 SEM at the base and apex of his heart
Abdomen: no guarding, no rigidity
Skin: WNL
Muscular/skeletal: no osteoarthritic changes, tibial and pedal edema 1+, PPP
Neurological: cranial nerves II-XII intact, no focal deficit, DTR present, there is severe fatigue, anxiety, insomnia, depression.

Assessment and Plan: 1. bronchitis, 2. bronchial asthma, 3. allergic rhinitis, 4. severe insomnia, 5. depression, 6. anxiety

Plan: Albuterol neb in the office X1, Singulair 10 mg. once/day, Ambien 15 mg. recommend: Selective Serotonin Reuptake Inhibitors
recommend: psychiatric evaluation and analysis
recommend: cessation of alcoholic consumption (patient estimates 1 liter of wine/day, various alcoholic drinks in addition)
recommend: cessation of smoking (patient admits to recurrent but somewhat infrequent use of menthol and clove cigarettes)

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4 Responses to “Progress Sheet”

  1. Rachel 02/04/2007 at 2:52 PM #

    Sounds like the makings of not so great weekend…and a lot of recommendations…

  2. Anonymous 02/04/2007 at 2:59 PM #

    Ah no. Sounds liek the makings of a good weekend to me. But, the label says: Fiction
    J

  3. choochoo 02/04/2007 at 3:11 PM #

    Sounds like interesting times. What if you dip the filter of the cigarettes in cough syrup?

  4. xi 03/04/2007 at 2:02 AM #

    = human. or something like it.
    nice fiction.

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