Student name:

Alyssa Matulich Date: 2/17/19

UTC SON Health Clinic

Patient’s Name: K.C Date of Birth: 1975 Date of Office Visit: 3/6/19

Reason for Visit:

HPI: Pt came in today for a yearly exam. With vitals pt blood pressure was 137/90 and 140/90 in office. Pt states she has a
history of high blood pressure and used to be on medication but came off about three years ago and has not had any issues
with her blood pressure since then. Denies headaches, palpatations, dizziness, lightheadedness, and palpatations. She was
taking lisinopril 10mg and it managed her blood pressure well. Pt states that she was not surprised it was elevated because
she is under a lot of stress. Pt states that she owns her own business, her daughter just told her she was a lesbian, and her
grandmother passed away a month ago. She states that since her daughter told her that she was a lesbian she was been
very upset. She states that she was having a hard time already having lost her mother about a month ago but now her
emotions are even more all over the place. Pt was wanting to possibly start on a medication to help her through this tough
time. She is just so overwhelmed and doesn’t know where to go or what to do and it is starting to affect her marriage and
business. Denies suicidal thoughts. Pt states that her periods have started to spread out and do not come every 28-30 days
anymore. One time she states her period was two weeks late and then she had another period 22 days after that and then
she "missed" her next period completely. LMP 1/19/19. She states that she has moderate bleeding with her periods and
recently they have been more painful and heavy with cramps over the past 3-4 months. She states that her mother had a
hysterectomy at 33 and her grandmother had one at 40. No history of uterine or ovarian cancer. Pts husband had a
vasectomy fifteen years ago. Pt states she had been working on losing weight and lost 25 lbs but over the past few weeks
she has gained 5-10 pounds. Last Pap Feb 2018. Last mamogram 2/5/2019.

Past Medical History (illnesses, surgeries, hospitalizations, etc.): pt had gallbladder removed five years ago. She has only
been hopitalized for the deliveries of her three babies vaginally. Pt has a history of HTN but has been off medication for
about three years.

Family History: Denies history of diabetes, CA, heart disease, and thyroid disorder, migraines, and HTN.

Social History: Pt lives at home with her husband and 18 year old son. She runs her flower business out of her home. Her
husband is a pastor and she is very involved in her church.

Have you ever used tobacco? Yes Never smoked

Number of packs per day:     
Quit:     (year)
Number of years smoking:     
Do you plan to quit?
Yes No When?
How much alcohol do you drink? Yes None
How much? Less than 7 drinks per week
Have you ever used illicit drugs? Yes No
More information:      
Do you exercise? Yes No
How often? Rarely
What do you do? Walking
What does your diet consist of? 24 hour diet recall: Breakfast: oatmeal and english muffin. Lunch
chicken salad and crackers, dinner chicken breast and broccoli.

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 Do you eat vegetables? Yes, a few times a week
Do you eat sweets? Yes, a few times a week
Do you drink water? Yes, everyday
Do you drink caffeine?
Yes No
Are you sexually active? Yes No In the past, but not currently
How many partners in the last 12 months? 1
How many lifetime partners? 1

Medications: Denies taking any medication. Allergies & Reaction: NKA

REVIEW OF SYSTEMS
If positive, mark with an X and describe further. If all negative, select ‘denies all’. If not performed, leave blank.

Constitutional: Fever Chills Fatigue Weight gain Weight loss Diet changes Denies all Notes: Pt states she
had been working on losing weight and lost 25 lbs but over the past few weeks she has gained 5-10 pounds probably due
to stress.

Eyes: Itching Burning Vision changes Discharge Denies all Notes:      

ENT: Sore throat Hoarse Nosebleed Ear pain Drainage Congestion Dental problems Denies all
Notes:      

Respiratory: Shortness of breath Cough Sputum Wheezing Denies all Notes:      

Cardiovascular: Chest pain Palpitations Racing heart Edema Dyspnea on exertion Denies all Notes: Pt states
that there are times when she feels overwhelmed and her heart races because of the stress.

GI: Abdominal pain Nausea Vomiting Heartburn Dysphagia Constipation Diarrhea Melena
Hematochezia Denies all Notes:      

GU: Urinary frequency Burning Itching Vaginal Discharge Pain with sex Denies all Notes:      

Female: Breast pain Breast lumps Breast discharge Heavy bleeding Painful periods Irregular periods
Denies all Notes: Pt states that her periods have started to spread out and do not come every 28-30 days anymore. One
time she states her period was two weeks late and then she had another period 22 days after that and then she "missed"
her next period completely. She states that she has moderate bleeding with her periods and recently they have been more
painful with cramps over the past 3-4 months. She states that her mother had a hysterectomy at 33 and her grandmother
had one at 40. No history of uterine or ovarian cancer.

MS: Pain Stiffness Swelling Joint pain Denies all Notes:      

Hematology / Lymph: Bleeding Bruising Enlarged lymph nodes Tender lymph nodes Denies all Notes:      

Endo: Excessive thirst Cold intolerance Heat intolerance Night sweats Hair loss Denies all Notes: Pt states
she has started to have night sweats and hair thinning over the last six months.

Skin: Rash Lesion Ulcer Pigment changes Changing moles Nail problems Denies all Notes:      

Psych: Sadness Irritability Suicidal thoughts Anxiety Insomnia Sleep problems Denies all Notes: She

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 states that since her daughter told her that she was a lesbian she was been very upset. She states that she was having a
hard time already having lost her mother about a month ago but now her emotions are even more all over the place.

Neuro: Headache Numbness Tingling Burning Pain Dizziness Vertigo Denies all Notes:      

Immune: Environmental allergies Sneezing Rhinorrhea Denies all Notes:      

Additional ROS information:      

PHYSICAL EXAM
Height 5'1" Weight 212lbs BMI       BP 137/90 T 98.8 P 91 R 16 Pain 0/10 Reason for pain:     

General: middle aged caucasian women, sitting on edge of bed

Skin/Hair/Nails: Skin is warm, dry, smooth and clean throughout. Color is appropriate for race. Hair on scalp is
thin, dirty blonde, shoulder length bob, and straight. Nails on hands are clean, well-groomed, firm and without
deformities.

Eyes: Sclera white bilaterally.

ENT/Mouth: Buccal mucousa intact throughout.

Neck/Thyroid: Neck is symmetrical without deformities. Thyroid midline, symmetrical, without enlargement or
tenderness.

Lungs: CTA throughout bilaterally. Symmetrical chest expansion.

CV: Heart RRR. S1 and S2 equal. No splitting, gallops, rubs, murmurs, or snaps.

Breasts: Medium sized breasts, pendulus, nipples symmetrical, No skin changes, nipple discharge, retraction,
lesions, masses or tenderness appreciated on exam. No lympadenopathy in axillary region bilaterally

Abdomen: Flat, soft, and symmetrical without tenderness in all four quadrants. Bowel sounds active in all four
quadrants.

Female Genitalia:

Vagina: Vaginal walls are ruggated, light pink and moist without lesions.

Cervix: Pink and smooth. No friability of cervix. No cervial motion tenderness. No discharge coming
from cervical os

Uterus: Small, midline, firm, smooth, mobile, and non-tender

Adnexa: No masses or tenderness with palpation

Rectum:      

MS: Upper and lower extremities with full ROM and strength 5/5.

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Neuro: A&Ox3.PERRLA. Speech clear and organized.

Lymph: No pre/postauricular, ant/posterior cervical chain, occipital, submandibular, submental,

supraclavicular,

infraclavicular, axillary, inguinal node lymphadenopathy

Psych: Pt cooperative during interview. Tearful when talking about daughter and mother.

Additional PE information:      

In-Office Diagnostics and Results:

UPT- negative

Differential Diagnoses (provide rationales and references):

1. Hypertension●Normal blood pressure – Systolic <120 mmHg and diastolic <80 mmHg ●Elevated blood
pressure – Systolic 120 to 129 mmHg and diastolic <80 mmHg ●Hypertension: •Stage 1 – Systolic 130 to
139 mmHg or diastolic 80 to 89 mmHg •Stage 2 – Systolic at least 140 mmHg or diastolic at least 90
mmHg. (Up to Date 2018) This pt has had 2 reading with the systolic higher than 140 and diastolic over
90.
2. Depression- Mood state, as indicated by feelings of sadness, despair, anxiety, emptiness,
discouragement, or hopelessness; having no feelings; or appearing tearful. Depressed (dysphoric) mood
may be normal or a symptom of a psychopathological syndrome or a general medical disorder. Minor
depressive episodes consist of depressed mood plus one to three other symptoms of major depression,
last for a minimum of two weeks, and cause clinically significant impairment or distress.
3.
4.      
5.      
6.      
Additional information:      

Assessment (ICD 10 codes, visit level codes, CPT codes):

Visit code-99214
Routine exam with normal findings- Z01.14
HTN I10
Depression F.33
UPT- 81025

Plan (evidence-based diagnostics, treatments, patient education, health promotion, health maintenance,
referrals, and follow-up for each assessment diagnosis):

Hypertension
- Start lisinopril 10mg 1 tab daily. Educated pt about possible side effects.
- Encouraged at home monitoring of bp twice daily and keeping a diary of blood pressures.
- Discussed life style changes to aid with lowering blood pressure like low fat diet and increasing exercise
- Follow up in two weeks. Pt to call the office if experiencing side effects of medication. Go to ED if
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experiecning chest pain or headache that is extremly painful and does not go away.
- Pt requests lab work to be preformed at next visit. Will run CBC, BMP, lipid panel, Thyroid panel, and
hormones at visit in to weeks.

Depression
- Start Lexapro 10mg daily.
- Discussed side effects and BBW of increased suicidal risk.
- follow up in two weeks.

Menopause
- Educated pt about peri-menopause and what to expect while transitioning into menopause. Educated pt that
some of the symptoms she is experiencing may be related to stress, thyroid, and other conditions at this time.
- Symptoms may include night sweats, sleep disturbances, hot flashes, dry thinning skin, etc
- Discussed possbile treatments if neccessary

Health Promotion and Prevention

- Alocohol consumptions- disscussed limiting alcoholic beverage intake on one per day and not binge drinking
- Yearly gynecological exam and pap starting at 21 or three years after first sexual encounter.
- Continue getting mammograms yearly per pt choice.

Additional Information:

Provider signature: Alyssa Matulich Date: 3/8/19

References:
Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2016). Guidelines for nurse practitioners in gynecologic
settings (11th ed.). New York, NY: Springer Publishing Company, LLC.

Basile, J., & Bolch, M. (2018, September 25). Overview of hypertension in adults. Retrieved from Up to Date