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Paeaonline.org

Practice Management Issues for the Physician Assistant:
Evaluation and Management
Chart Note Exercises
EXAMPLE # 15:
New Patient
Patient:
Problem List:
1. Type 2 diabetes, recent diagnosis.
2. Hypercholesterolemia.
3. S/P TAH/BSO 1976.
Meds:
1. Avandamet 500/4 bid .
2. Zocor 20 mg daily.
Allergies:
Aspirin (itching).
Social History:
Nonsmoker, nondrinker. Married, no children. Works as a secretary.
Family History:
Positive for diabetes.
43 year old female comes in for first visit with 2 week history of rightthigh pain. Feels that it is swollen, radiates down to her knee and hasbeen gradually progressive. It is there from the moment she wakesup, lasts all day long. Has no position that is better or worse although stairs are difficult for her to deal with. She has tried Tylenol 500 mg 2tabs bid without much relief. Denies any direct trauma to this area,did have some tingling in the affected area, but no numbness orweakness of her feet. It is to a point now that it is affecting her ability to function. She has to go up and down many stairs at work.
Recently diagnosed as diabetic by her previous provider. Denies any hypo- or hyperglycemic symptoms, reports her blood sugar ranges 145-200 at home. She is not having any problems with the medications. Wishes to transfer care here for convenience of location.
Wt 222 lbs, T 97.5, P 95, R 18, BP 128/85. Fingerstick glucose 168.
General: well nourished, well developed, pleasant, over weight Right leg without deformity, skin changes, or visible masses.
She is tender to palpation over the right anterior upper quadriceps region as well as right lateral upper thigh below the trochanteric bursa.
Moderate amount of pain elicited with range of motion, particularly with right hip flexion as well as right knee extension.
Straight leg raise is negative, although her pain worsens in the anterior thigh to feeling like a cramp such that she had to stand up and shake it off.
5/5 strength of her lower extremities except could not fully assess herhip flexors or knee extensors due to her pain.
DTRs are bilaterally symmetrical.
Sensation intact to soft touch and vibration.
1. Right leg pain of unclear etiology.
2. Diabetes, borderline control.
1. CBC, chem 7, sed rate, TSH, CK, calcium and magnesium levels. Also check urine for myoglobin. X-ray right femur and hip. If those are all normal, we will probably start her on an anti-inflammatory and set her up with physical therapy. Also work excuse given for the rest of this week that she should not do any stairs. Telephone follow-up re test results and plan.
2. For now continue with current medications. Request records from previous provider. Will need hemoglobin A1c, lipid panel, LFT’s, microalbumin screen, and eye exam on appropriate schedules. Check pneumovax and flu vaccine status. Return appointment in one month,at which time hopefully old records will be available.

Source: http://www.paeaonline.org/Project04/PM/html/EM/PDF/em_chartnote15.pdf

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