MEDICAL TRANCRIPTION M3.A1
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Sistema Universitario Ana G Mendez *
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116
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Medicine
Date
Apr 3, 2024
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docx
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SISTEMA UNIVERSITARIO ANA G MENDEZ RECINTO ONLINE.
MEDICAL TRANSCRIPTION
MODULO 3
PATIENT NAME: Carl Ewing
MEDICAL RECORD NUMBER: 5477211
DATE OF SERVICE: 02-02-2024
DOCTOR: Dr. Sabrina Scott.
CLINIC NOTE.
REASON FOR VISIT: Mr. Ewing is a 55 years old gentleman seen in our clinic for the first time
to establish primary care.
HISTORY OF PRESENT ILLNESS: First, His most troublesome problem has been his right sciatica, a problem for twelve years. It waxes and wanes, apparently in relation to how much time he spends on international travel sitting in a plane. He occasionally requires taking Vicodin to relieve the pain.
He also continues to have some quote, spasms and quote in the left side of the neck and trapezius
area for which he takes Neurontin 600 milligrams two to three times for day.
He has depression and this is worsened lately. He makes a suicide attempt 8 to 9 months ago. He currently is on Lexapro 40 milligrams daily, which he states has proved to be very beneficial. He
seen Dr. Scott Steinberg. He is in a very bad, nearly intolerable second marriage situation to an alcoholic, abusive wife. That relation is anticipated to end in divorce in the near future.
REVIEW OF SYSTEMS: He genuinely feels healthy for the last six weeks, he has noted a headache a couple of times per week, usually in the glabellar area, usually in evening. He treats it
with extra strength Tylenol. He recently has noticed some mild tinnitus in the right ear. He has no cardiopulmonary symptoms. He has no trouble passing his stool since surgery for hemorrhoids a number of yeas ago. He has no genital, urinary, or musculoskeletal symptoms.
SOCIAL HISTORY: He continues to enjoy his career as a stockbroker. He travels extensively internationally. No tabacco, minimal alcohol, no exercise.
FAMILY HISTORY: His father and two paternal uncles have had prostate cancer. His father, aged 75, is currently being treated. His mother is an alcoholic. His two brothers enjoy good health. A daughter has trouble with depression and has made a suicide attempt. A son has psychiatric illness.
MEDICATIONS:
1.
In addition to Lexapro, he takes Ambien 10mg QHS.
2.
Allegra 100mg QD.
3.
Nasonex two times per day.
4.
Prilosec as needed.
5.
Extra strength Tylenol tree at bedtime.
6.
Saw Palmetto.
7.
Fish oil Concentrate.
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ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: His blood pressure was 125/75, pulse 72, height 5 feet 10 inches,
and weight 220lbs. He appears healthy, but a bit depressed and modestly overweight. He has no significant cutaneous abnormalities. HENT is unremarkable. His thyroid and carotid are normal. He has no adenopathy.
His chest, heart and abdomen are normal genitalia are unremarkable. His prostate is normal. Peripheral pulses are readily palpable. Vibratory sensation is intact, straight leg raising equivocally positive at 60° on the right limited range of motion of the neck and shoulder girdle. Reflexes are all easily elicited, able and symmetric.
ASSESSMENTS: 1.
Go to general health.
2.
Depression on Lexapro
3.
Degenerative Disc-Disease, lumbar spine with right sciatica.
4.
Allergic rhinitis currently doing well.
5.
Neck slash depresses spasm. Unclear ideology.
6.
Family history of prostate cancer, depression and alcoholism.
PLAN: He will have an EKG
and blood drawn for chemistries, CBC, LFTS and lipid profile which we will review with him later in the day.
That’s the end for clinic note for Carl Ewing and the end for this dictation. Thank you.
RFERENCIAS:
Sistema Universitario Ana G Mendez Recinto Online.Medical Transcription. Modulo 3
Canvas LMS (instructure.com)
Sistema Universitario Ana G Mendez Recinto Online.Medical Transcription. Modulo 3
Módulo 3: Materiales y Recursos: Medical Transcription_OSMB111_OS001_MAINSPA_SPOL_2024SPR-71 (instructure.com)