neidacaroboone-editngM-97

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Valencia College *

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1611C

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Medicine

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Dec 6, 2023

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Internal Medicine Clinic Follow up Note Patient Name : Oma Gaye Enderle PCP : Joshua Gatlin, MD Date of Exam : 28 July ---- Age/Sex : 69/Female ID# : M-97 REASON FOR VISIT : Annual preventive visit. HISTORY : Ms. Enderle is a pleasant 69-year-old lady with a past medical history significant for ankylosing spondylitis with restricted lung disease, gastroesophageal reflex disease, hypertension, and depression. Patient reports that she has been doing okay recently. She has had no cute changes in her health. She states that she will be moving to Ohio in the middle of next month. She will be coming back to Miami intermittently. Patient reports no significant change in her shortness of breath. She does not wear oxygen during the day. She does wear oxygen at night. She has previously been followed in the pulmonary clinic. She has restrictive lung disease secondary to her kyphosis from her ankylosing spondylitis. REVIEW OF SYSTEMS : Ms. Enderle denies headaches and visual changes. She has had no difficulty swallowing or speaking. She has had no pain with swelling. Denies epigastric pain, nausea, vomiting, abdominal pain, bright red blood per rectum, and melena. She has had no cough or hemoptysis. She has had no urinary incontinence or dysuria. No new musculoskeletal complaints. She is sleeping okay, and her mood has been okay. PAST MEDICAL HISTORY 1. Ankylosing spondylitis. 2. Restrictive lung disease. 3. Gastroesophageal reflux disease. 4. Hypertension. 5. Depression. 6. Likely osteoporosis.

Patient has been unable to perform a bone mineral density chest secondary to her limited ability to lie flat secondary to her ankylosing spondylitis. PAST SURGICAL HISTORY : Has had cataracts removed from both eyes. FAMILY HISTORY : She has a daughter with diabetes. Her sister has a history of breath cancer. There is no family history of coronary artery disease. Internal Medicine Clinic Follow up Note Patient Name: Oma Gaye Enderle Date of Exam: 28 July ---- ID#: M-97 Page 2 SOCIAL HISTORY : Patient quit tobacco in 1985. She had an approximate 8- pack-year history. She has never been a drinker, is not socially active. MEDICATIONS 1. Fosamax 70 mg weekly. 2. Tolmetin DS 400 mg t.i.d. p.r.n. 3. Flexeril 10 mg p.r.n. 4. Lopressor 100 mg b.i.d. 5. Hydrochlorothiazide 25 mg daily. 6. Prevacid 30 mg daily. 7. Combivent 2 to 4 puffs p.r.n. 8. Advair Diskus 250/50 mcg, 1 puff b.i.d.

9. Celexa 40 mg daily. ALLERGIES : No known drug allergies. PHYSICAL EXAMINATION : Blood pressure 132/58, pulse 83, respirations 20, temperature 99.1, height 5 feet 3 inches, weight 65.5 kg. She denies pain. In general, she is a well-nourished, well-developed Caucasian lady in no acute distress. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles intact. Tympanic membranes clear bilaterally. Oropharynx is moist and pink without erythema or exudates. NECK: Supple without buris. CARDIOVASCULAR EXAM: Regular rate and rhythm with normal F1, S2 and no S3 or S4. No murmur. CHEST: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended with no organomegaly. LOWER EXTREMITIES: No clubbing, cyanosis, or edema. MUSCULOSKELETAL: Patient has notable kyphosis to approximately 30 degrees. BREAST EXAM: Patient has no skin changes. There is no palpable axillary lymphadenopathy. No palpable masses. LABORATORY DATA : Recent laboratory studies dated 18 July: Vitamin B12 330, folate 13.6. White blood cells 7.1, hemoglobin 11.2, hematocrit 35, MCV 79.3, platelets 355. Reticulocyte fraction is elevated at 0.380. LFTs are within normal limits. Glucose 79, BUN 28, creatinine of 0.9, sodium of 139, potassium 4.2, calcium 9.3, albumin 4.3. Iron 24, TIBC is elevated at 419, iron saturation at 6%, and ferritin is low at 21. Internal Medicine Clinic Follow up Note. Patient Name: Oma Gaye Enderle Date of Exam: 28 July ---- ID#: M-97 Page 3 ASSESSMENT : A 69-year-old white lady with past medical history as listed above. She is doing okay at this time with new finding of iron-deficiency anemia.

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PLAN 1. Iron-deficiency anemia: Patient had a colonoscopy in the early 1990s. She has had no recent screaming. Discussed with her the importance of follow up gastroenterology appointment for consideration of upper and lower endoscopy. In the meantime, she is to begin iron 325 mg b.i.d. She is currently asymptomatic with no chest pain, shortness of breath, or lightheadedness. 2. Ankylosing spondylitis: Patient has been followed in the rheumatology clinic. She takes tolmetin and Flexeril p.r.n. pain. She has no acute complaints, and these meds have worked for her in the past. 3. Gastroesophageal reflux disease: Patient's symptoms are well controlled with Prevacid 30 mg daily. She is to continue this at recurrent dose. 4. Hypertension: Good control on Lopressor and hydrochlorothiazide. Will continue these at their current doses. 5. Depression: Patient is euthymic. She is to continue her Celexa 40 mg daily. 6. Osteoporosis: Patient is to continue her Fosamax 70 mg once daily with calcium and vitamin D. She has had no recent follows. 7. Restrictive lung disease: No recent change in her symptoms. She is to continue to wear her oxygen at night as directed by the pulmonary clinic. 8. Healthcare maintenance: Patient had a pneumococcal vaccine 3 years ago. She receives the influenza vaccine annually. She had an eye exam 2 years ago. Her last mammogram was in February last year. Her annual screening mammogram has been ordered. Patient's lipid profile was checked this January and was at goal. Internal Medicine Clinic Follow up Note Patient Name: Oma Gaye Enderle

Date of Exam: 28 July ---- ID#: M-97 Page 4 DISPOSITION : Patient is to follow up with her new PCP in Ohio as soon as she establishes residency. We will forward her records on request. I told her that she is welcome to follow up with me at any time she returns to Miami. ____________________________________ Jean W. Mooney, PA, Internal Medicine JWM:xx D: 7/28/---- T: 7/29/---- c: Luke Mosbacker, MD, Rheumatology Clinic, Joshua Gatlin, MD, Pulmonology Clinic.

neidacaroboone-editngM-97

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