In This case there is 6 codes. New patient consultation Subjective This 32-year-old female was referred to me by Dr. K

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In This case there is 6 codes.
New patient consultation

Subjective

This 32-year-old female was referred to me by Dr. Keating from the
Emergency Room last weekend. She does not currently have a family
practitioner and would like to establish care with me as such. She
is presenting with complaints of chest pain and shakiness. She has
had previous episodes for approximately four years, suddenly worse
over the last couple of weeks, increasing in intensity and
frequency, without any triggers. These episodes are often
accompanied by SOB and feelings of panic, shakiness, and sweaty
palms. She has not been treated for this. She reports feelings of
depression on and off for most of her life and has a strong family
history of this as well as family history of diabetes, heart
disease, and thyroid disorders. She denies suicidal thoughts. She
has trouble sleeping occasionally and fatigue. The patient drinks
occasionally and smokes 1- 2 packs per day. Current meds: none.
NKDA. No G.I. or GU complaints. Her past medical history is
significant only for cesarean section and gestational diabetes 13
years ago. And cervical dysplasia around that time as well. She has
the one child and works full-time. Remainder of systems and history
are negative.

Objective:

BP: 190/86 HT: 5’3” WT: 198 lbs. Temp: 98.6.
General: Obese white female, tearful and anxious. Face and neck are
flushed.
HEENT: enlarged tonsils.
Neck: Enlarged thyroid.
Abdomen: WNL
Lungs: Clear to auscultation and percussion.
Heart: WNL.
EKG: WNL.
Repeat BP: 144/74.
Assessment:
1. Anxiety.
2. Depression.
3. Elevated BP
4. Fatigue
5. Goiter
6. Obesity

Plan:

1. Labs: comprehensive metabolic panel, TSH, CBC, and lipid
panel
2. Lorazepam 0.5 mg 1- 2 times qd prn
3. Lexapro 20 mg qd