Patient Intake

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for a first visit



Past medical history: ‍



Medications: ‍



Allergies: ‍NKDA, ‍



Family history: ‍none, ‍



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonereasonableexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Occupation: ‍

Living with: ‍





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Breasts: ‍normal, ‍mass, ‍axillary adenopathy

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Genital: penis ‍normal, testes and epididymis ‍normal, ‍inguinal hernia

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





PLAN:

Investigations:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍HbA1c, ‍lipid profile, ‍TSH, ‍Vitamin D, ‍Iron studies, ‍PSA

- Urinalysis

- ECG

- Chest X-ray

- Mammogram

- Pap smear

- Bone density scan

- Colonoscopy

- Vision screening

- Hearing screening

Treatments:

- Lifestyle counseling: ‍balanced diet, ‍exercise, ‍smoking cessation, ‍alcohol moderation

- Immunizations: ‍influenza, ‍pneumococcal, ‍Tdap, ‍shingles, ‍HPV

- ‍Vitamin D

- ‍Calcium

Further care:

- Referral to dietitian

- Follow-up in ‍ ‍weeksmonths

- Return if new symptoms develop