1234 Your Street Hometown TX 72345 US Mary J Smith 2222 Home Street Beaverton OR 97867 US Boris Bo Betterhalf 4444 Home Street Beaverton OR 97867 US 54300 Medical Drive Hometown TX 72356 US John T. Provider, Healthy You, LLC 54300 Medical Drive Suite 123 Hometown TX 72356 US 54300 Medical Drive Hometown TX 72356 US MaxMD FHIR Connectathon16 MaxMD CCDA Creator John T. Provider, LLC 54300 Medical Drive Hometown TX 72356 US 54300 Medical Drive Hometown TX 72356 US John T. Provider, LLC Consent to Treat

Hip pain.

Follow up blood pressure.

Degenerative joint disease: Her right hip is especially affected. She attributes the pain to working as a hairdresser for many years and standing on her feet for many hours. She uses Tylenol on a daily basis and takes Tramadol for exacerbations. Hypertension. Controlled on ACE inhibitors. Noninsulin dependent diabetes mellitus. On metformin and glyburide, currently not well controlled. Last hemoglobin A1c was 6.8.

Difficulty ambulating Mild hearing loss

Continue to live in own home with minimal assistance.

The patient is a 70-year-old white female with hypertension and chronic hip pain. She is here for her yearly comprehensive exam. Patient has been complaining of pain in her right hip for several years, which appears to be progressive. Eventually she will need a total hip replacement, but she is hoping to put this off as long as possible. She is keeping a blood pressure diary and says her blood pressure is under good control with lisinopril. She is unable to walk due to her hip pain and has not yet joined the YMCA as she intended to do water exercises. Being sedentary has exacerbated her diabetes and her blood sugars have not been well-controlled.

History of: 1. Degenerative joint disease. 2. Hypertension. 3. Noninsulin dependent diabetes mellitus.

Lisinopril 5 mg daily. Tylenol 500 mg every 6 hours p.r.n. pain Tramadol 100 mg every 4-6 hours p.r.n. severe pain Metformin 1000 mg each night Glyburide 1.5 mg each morning

4-point cane, Rollabout

Pneumovax 8/25/2007 Influenza 10/1/2016 Tdap 10/1/2006 Zoster (HZV) 10/1/2010

Widowed, lives alone. Nonsmoker, nondrinker. Retired hairdresser. House with one-step entry, no stairs. Daughter lives across the street and son lives nearby.

Father Rheumatoid arthritis Diabetes Hypertension Congestive heart failure Mother Osteoarthritis Diabetes Hypertension Brother Rheumatoid arthritis Sister Hypertension No history of cancer or early-onset cardiovascular disease.


Ciprofloxacin (severe; rash, difficulty breathing).

Head: No chronic headaches. Eyes: No diplopia. Gradually diminishing vision. Still wears glasses. No recent change in prescription. Ears: No tinnitus. Does have slightly decreased hearing. Nose: Seasonal rhinitis, chronic. No antihistamines on a regular basis. No epistaxis. Thyroid: Unremarkable. Pulmonary: No cough, no wheeze. Cardiac: No palpitations, no angina. Gastrointestinal: No melena or hematochezia. No abdominal pain or bloating. Genitourinary: Mild urinary stress incontinence. Musculoskeletal: No falls, no injuries. Right hip pain, mild left hip pain.

Weight: 185, note: up 6 pounds since her last visit. Blood pressure: 135/80 Pulse: 70 Heartbeat: regular

HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light and accommodation. Sclerae anicteric. Conjunctivae not injected. Fundi show no copper wiring or hemorrhage. Globes are soft. Extraocular movements were intact. Sinuses nontender. TMJ nontender. Temporal artery nontender. TMs were clear. Nares were clear. Pharynx without exudate. Tongue was midline. NECK: Supple. Good carotid upstroke. No bruits. No thyromegaly. No supraclavicular or axillary masses. Large postauricular lipoma on the right side, asymptomatic. No other nodules, no axillary masses. BREASTS: Supple, no masses. LUNGS: Clear. CARDIAC: No ectopy. No peripheral murmurs. No pitting edema. Pulses symmetric. ABDOMEN: Obese, nontender. Bowel sounds present. No masses, no organomegaly. No suprapubic pain. GU: Normal external female genitalia. Pelvic not performed. EXTREMITIES: No edema. Negative straight leg raising test. Negative Homans sign. Negative Gaenslen test. NEUROLOGIC: Awake, alert, and oriented. Moves all extremities. Symmetric reflexes. Vibratory intact, light touch intact, temperature intact.

GENERAL: Well-developed, moderately obese white female in no acute distress. Alert and oriented x3.

Need a results section for Mary.

Fasting labs. Mammogram per Dr. Hopkins annually. Colonoscopy. Bone density. See me back in a year unless a problem develops. Implement low-impact exercise plan such as water exercise. Follow ADA diet.