Identify a friend, peer, or family member you can interview to collect. information to construct a complete and comprehensive subjective data set consistent with documentation requirements for a new patient scheduled for an annual wellness exam.
Conduct an interview. Document your findings in a Word file. Structure the subjective data
set in the format provided in your lecture materials. Submit the Word file containing your subjective data set into
Canvas
Estimated time to complete: 1 hour
Kyle P
Chief Complaint: New Patient
Subjective:
CC: new patient wellness check
HPI: 33 years old male, being seen for comprehensive new patient examination. Denies current illness.
Patient subjectively reports increased urination and thirst. Reports nausea daily. Patient also reports some
mild visual changes when reading for longer period. Did not disclose the onset or duration of problem. Pt
reports ongoing diarrhea tries to control with use of OTC medication, pt reports swelling in lower
bilateral legs, ashy tone to both legs. Reports having ongoing neuropathy in both legs.
PMH
Diagnoses: HTN, DM 1, ED, Depression, Anxiety, IBS, chronic pain,
Hospitalizations: Multiple admits related to poorly managed DM unknown amount states around
10 or more
Surgeries: NA
DME:
Allergies:
Rx: NDKA
Food/Bev:NKA
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Environment: NKA
Medications/Therapies:
Rx: Insulin/ Humalog (sliding scale) ( Treat DM) AC/HS, gabapentin 300mg PO BID
( Neuropathy), Sildenafil 100mg PO PRN (For ED)
Supplements:
Alt. Tx. Modalities: Pepto Bismol, Tums
Social:
As it R/T CC:
Family and Home: Lives in a 2-bedroom apartment where he has non established split custody of
his 8-year-old son.
Edu/literacy: High school diploma, special training r/t job
Occupation/hazards/stressors: Auto Mechanic for 40 hours a week
Relationships: monogamous one partner
Sex/STD risk: no screens in past for STD, currently in one partner relationship
Drugs/Etoh/Tobacc/Caff: reports using THC for IBS and chronic pain uses daily particular at HS.
Reports vaping nicotine. Does not typically consume caffeine products other than 2 cups a coffee daily. Pt
reports only drinking alcohol socially. Drinks maybe once or twice a month 1-2 cans beer.
Cult/Spiritual: Denies spiritual
$$ circumstances: pt reports not having medical insurance and reports that he makes too much to
qualify for Medicaid, pt also reported that he was told by employer due to his medical history he could
not obtain their medical insurance.
FMH:
Maternal: living- reports that she is addict with ongoing mental health issues
Paternal: did not disclose
Children: Son(8)- type one diabetes
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Siblings: did not disclose
Wellness:
General:
Vaccines/PPD: reports only receiving childhood vaccines, denies any boosters
Activity level: denies daily exercising. Reports that work exhaust him, reports always feeling
tired and reports poor sleep patterns
Diet: low carb/ diabetic friendly
Dental/Vision: states that it has been over 3 years since last exam for eye and dental. Trouble
reading for long periods burry vision
Screenings: reports labs only when admitted for DM,
BMI: 5’6”, 130lb
General: well groomed, 33-year-old white male. Appears slightly anxious
VS: 156/112, 112, 18, 98%, 5’6”, 130lb Chronic pain 6
Skin: edema, ashy tone to bilateral legs
HEENT: reports glasses when reading
Neck: wnl
CV: HTN, tachycardia
Lungs: diminished
GI: ongoing diarrhea, Abdomen: nodules from constant insulin injection, soft non distended, bowel
sounds in all 4 quad.
GU: increased urination, increased thirst
PV: edema bilateral lower extremities, ashy tone to legs +2 cap refill to legs, neuropathy to legs ongoing
pain
Musculoskeletal: wnl
Neuro exam: anxiety, depression
Diagnostic Tests:
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Reproductive: ED for past 2/3 years
Immune/Rheum:
ASSESSMENT:
Diagnoses: Patient in for new patient wellness appointment. DM 1 poorly managed only using Humalog
short acting, not receiving long acting, HTN poorly managed not receiving treatment, ED- poorly
managed reports medication is only partially effective, chronic pain- controlled with medication
gabapentin, IBS- poorly managed only treating with OTC.
PLAN:
For each Dx above: If N/A, include why/why not
Diagnostics:
Therapeutics:
Education:
Consult:
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