Clinical Documentation Template Subjective Chief Complaint: 52 year old male present for three month follow and labs check. HPI: A 52-year old male with PMH of Hyperlipidemia diabetes presents to the clinic for three month follow up. Patient complained of polyuria, polydipsia and polyphasia. Patient is presently taking plavix and sexagliptin. Patient denies any chest pain, fever and chills. ROS General: lost 15lbs in last one month, admit weakness, fatigue. Denies depression, suicide throught. Skin: no rashes, no open wound.. Head: Denies headache, head injury, dizziness. Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness. Ears: no hearing change, tinnitus, infection, discharge. Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis. Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago. Neck: No lumps, swollen glands, goiter, pain, or neck stiffness. Neuro: experience syncope once a week, denies seizures, weakness, paralysis, numbness/tingling, tremors, or involuntary movements. Pulmonary: negative hemoptysis, dyspnea, wheezing,pleuritic pain Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots, abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness, pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather. Swelling with redness or tenderness. MS: no muscle, joint pain, or joint stiffness. GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain, belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food intolerance, indigestion, nausea, vomiting, early fullness, odynophagia. GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria, nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids. O: Past Medical History: Hyperlipidemia, diabetes Surgeries: Appendectomy, 2000 Hospitalizations: 2000 (for appendectomy) Allergies: NKDA Food, drug, environmental: None Medications: Plavix 75 mg daily (prescribed by his PCP in INDIA as a prophylaxis to prevent Heart attack. We use Aspirin 81 mg here in USA) Sexagliptin 5 mg daily Family History: Gout (Father) Diabetes (Mother) . Social History: Denies tobacco/e-cigarette and alcohol use. Objective Vital Signs: Temp 98.2 BP 128/90 Pulse 64 RR 18 Pain 0 Height 5’ 8” Weight 140 lb BMI 21.3 SpO2 97% @ RA Labs: Lipid Panel Cholesterol 272 mg/dl Triglyceride 175 mg/dl HDL 28 mg/dl LDL 135 mg/dl HgA1c 9.8% Physical Exam: HEENT: Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumati.

1. Clinical Documentation Template
Subjective
Chief Complaint: 52 year old male present for three month
follow and labs check.
HPI: A 52-year old male with PMH of Hyperlipidemia diabetes
presents to the clinic for three month follow up. Patient
complained of polyuria, polydipsia and polyphasia. Patient is
presently taking plavix and sexagliptin. Patient denies any chest
pain, fever and chills.
ROS
General: lost 15lbs in last one month, admit weakness, fatigue.
Denies depression, suicide throught.
Skin: no rashes, no open wound..
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness,
excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth.
Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: experience syncope once a week, denies seizures,
weakness, paralysis, numbness/tingling, tremors, or involuntary
movements.
Pulmonary: negative hemoptysis, dyspnea, wheezing,pleuritic
pain

2. Peripheral vascular: no claudication, leg cramps, varicose veins,
history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs.
Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in
fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness.
GI: No changes in appetite, excessive hunger or thirst, jaundice,
N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia,
melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness,
odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency,
hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain,
ureteral colic, hemorrhoids.
O:
Past Medical History: Hyperlipidemia, diabetes
Surgeries: Appendectomy, 2000
Hospitalizations: 2000 (for appendectomy)
Allergies: NKDA
Food, drug, environmental: None
Medications: Plavix 75 mg daily (prescribed by his PCP in
INDIA as a prophylaxis to prevent Heart attack. We use Aspirin
81 mg here in USA)
Sexagliptin 5 mg daily

3. Family History: Gout (Father)
Diabetes (Mother)
.
Social History: Denies tobacco/e-cigarette and alcohol use.
Objective
Vital Signs: Temp 98.2 BP 128/90 Pulse 64 RR
18 Pain 0 Height 5’ 8” Weight 140 lb BMI
21.3 SpO2 97% @ RA
Labs: Lipid Panel
Cholesterol 272 mg/dl
Triglyceride 175 mg/dl
HDL 28 mg/dl
LDL 135 mg/dl
HgA1c 9.8%
Physical Exam:
HEENT:
Head: hair normal texture and distribution, no
lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with
palpation. Skull normocephalic/atraumatic.
Eyes: no drainage noted, no hemorrage.
Ears: pinna clean, no exudate noted. TM intact and pearly gray
with cone of light bilateral .
Nose: nasal mucosa pink and moist. Inferior turbinates slightly
reddned bilat. Nares patent bilat. No sinus pain upon palpation.
Septum midline.
Throat: no swelling of the lymph nodes.
Neck: non-tender cervical area, no lymph nodes palpable. Non-
enlarged thyroid palpated. Trachea midline.

4. Neuro: Alert and oriented x 4, CN I – not tested, II-XII intact.
Deep tendon reflexes 2+ Brachioradialis, bicep, triceps,
supinator, knee, and ankle with plantar reflexes down-going. No
clonus. Muscle strength 5/5.
Thorax and lungs: Thorax is symmetric with good expansion.
Respirations are even and unlabored. No use of accessory
muscles, nasal flaring.
Cardio: JVP is 3cm. above the sternal angle with the head of
bed elevated to 30 degrees. Carotid upstrokes are brisk without
bruits. Temporal arteries have normal pulsation without
tenderness. The point of maximal impulse is taping, 8 cm lateral
to the mid-sternal line in the 5th intercostal space. Crisp S1 S2
without clicks or murmurs. Extremities are warm and without
edema. No variscosities or stasis changes. Calves are supple and
non-tender. No femoral or abdominal bruits. Brachial, radial,
femoral, popliteal, dorsalis pedis, and posterior tibial pulses are
2+ and symmetric. Ca refill <2 secs.
Abdomen: soft flat, non-tender and non-distended. Normoactive
bowel sounds. No palpable masses or hepatosplenomegaly.
Liver span is 7cm in the right midclavicular line. Edge not
palpable. Kidneys not felt. No CVA tenderness.
MS: Full active range of motion in all joints of the upper and
lower ext. No evidence of swelling or deformity .
Skin: dry skin, no open wound, feet look fine
Male Genitalia: deferred
Assessment
Differentials: 1. Diabetes mellitus type 1 2.
Latent autoimmune diabetes in adult 3. Chronic
renal Insufficiency.
Diagnosis: Diabetes mellitus 2, Hypercholesterolemia.

5. Plan And treatment : The cornerstone of therapy for all patients
with diabetes is a personalized self-management program,
usually developed with the patient by a diabetes education nurse
or nutritionist. Diabetes self-management education and
support facilitates diabetes self-care and assists in
implementation and sustainment of lifestyle changes on an
ongoing basis. This requires general nutrition and health
lifestyle knowledge and an individualized nutrition and exercise
plan based on an initial assessment and treatment goal.( ADA,
2018)
Diabetes mellitus: Stop Sexagliptin.
Start Metformin 500 BID, Glipizide 5
mg daily plus Actos 30 mg daily.
Hypercholesterolemia: Stop Plavix.
Start Lipitor 40 mg daily.
Aspirin 81 mg daily ( prophylaxis)
.
Education: Diabetes education and mentioned above plus
regular exercise. For high cholesterol, the adoption of a
healthier lifestyle, including a low-fat diet and a reasonable
amount of aerobic exercise, will have a large impact on the
prevalence of hypercholesterolemia, as well as of obesity and
coronary heart disease. Patient should follow with PCP in three
month.
Follow up: Three month
Reference

6. American Diabetes Association. Standards of medical care in
diabetes - 2018. Diabetes Care. 2018 Jan; 41(suppl 1): S1-159