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.

 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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