;

;

;

;

;

;

;

Benko, Kimberly Diann, APRN, ANPHYPERLINK "epic:EPIC?ACTIVITY2&UC_SECURE_CHAT&PATIENTID%3b+Z12893168&%20Z12893168%5EU36314%5E%5E%5E%5E&&&&EmpIDs%07%24EU36314%07%24FPatientID%07%24E%20Z12893168%07%24F&False&Default&False"

Nurse Practitioner
Family Medicine

Progress Notes

Signed

Encounter Date:12/20/2024

Signed

Expand AllCollapse AllFORMCHECKBOX
Expand All by Default

Assessment and Plan:
Annual physical exam
-     CBC with Differential; Future
-     Comprehensive Metabolic Panel; Future
-     Thyroid Stimulating Hormone; Future
-     Thyroxine, Free; Future
-     Lipid Panel; Future

Acute pain of right foot
-     Amb Referral to Orthopedic Surgery

Assessment
Assessment & Plan

Followup: No follow-ups on file.

History
Devin Slick is a 36 y.o. male who is seen today for Well Adult Exam (Pt is here for the annual exam and future lab work.)

Pt is here for annual exam he feels well he denies any real concerns
History of Present Illness

Observations
BP 110/80 (BP Location: Left Arm, Patient Position: Sitting, Cuff size: LAd)  | Pulse 64  | Temp 97.7 F (36.5 C) (Temporal)  | Resp 16
 | Wt 97.1 kg (214 lb)  | SpO2 98%  | BMI 29.85 kg/m
Physical Exam

Physical Exam

General appearance: alert, appears stated age, and cooperative
Head: Normocephalic, without obvious abnormality, atraumatic
Eyes: conjunctivae/corneas clear. PERRL, EOM's intact. Fundi benign.
Ears: normal TM's and external ear canals both ears
Nose: Nares normal. Septum midline. Mucosa normal. No drainage or sinus tenderness.
Throat: lips, mucosa, and tongue normal; teeth and gums normal
Neck: no adenopathy, no carotid bruit, no JVD, supple, symmetrical, trachea midline, and thyroid not enlarged, symmetric, no tenderness/mass/nodules
Lungs: clear to auscultation bilaterally
Heart: regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop
Abdomen: soft, non-tender; bowel sounds normal; no masses,  no organomegaly
Extremities: extremities normal, atraumatic, no cyanosis or edema
Skin: Skin color, texture, turgor normal. No rashes or lesions
Lymph nodes: Cervical, supraclavicular, and axillary nodes normal.
Neurologic: Grossly normal

Results

Documentation for this medical note was completed using Nuance DAX Copilot. This document reflects the decisions made by me. Some incorrect words or phrases may have been missed during proofreading. Kimberly Diann Benko, APRN, ANP

Electronically signed by Benko, Kimberly Diann, APRN, ANP at 12/21/2024 9:32 PM

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&19^%20Z12893168^54337^6581793118^54336^2103652283"Office Visit on 12/20/2024

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&19^%20Z12893168^54337^6581793118^54336^23045880001"Detailed Report

Note viewed by patient
Additional Documentation

Vitals:
BP110/80 (BP Location: Left Arm, Patient Position: Sitting, Cuff size:
LAd)

Pulse64

Temp97.7 F (36.5 C) (Temporal)

Resp16

Wt97.1 kg (214 lb)

SpO298%

BMI29.85 kg/m

BSA2.21 m

Flowsheets:
HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#2109200012,EPT,%20Z12893168,54337,,^7439^^^^^^^^^^54337^^^^^^^^^^^^^903036151"
Patient Health Questionnaire-9,

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#2109200012,EPT,%20Z12893168,54337,,^400603^^^^^^^^^^54337^^^^^^^^^^^^^903036151"
Vital Signs,

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#2109200012,EPT,%20Z12893168,54337,,^304001040^^^^^^^^^^54337^^^^^^^^^^^^^903036151"
Anthropometrics

Encounter Info:
HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#55030,EPT,%20Z12893168,54337"Billing Info,

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#55451,EPT,%20Z12893168,54337"History,

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#55020,EPT,%20Z12893168,54337"Allergies,

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#2100000025,EPT,%20Z12893168,54337"Detailed Report

Print Note Only

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#2102110001,EPT,%20Z12893168,54337"Print Note Only

Comprehensive Note

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#21012621100,EPT,%20Z12893168,54337"Comprehensive Note

Orders Placed

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&6^%20Z12893168^1348920385^^^^0"CBC with Differential

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&6^%20Z12893168^1348920386^^^^0"Comprehensive Metabolic Panel

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&6^%20Z12893168^1487518496^^^^0"Lipid Panel

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&6^%20Z12893168^1487518494^^^^0"Thyroid Stimulating Hormone

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&6^%20Z12893168^1487518495^^^^0"Thyroxine, Free

HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&6^%20Z12893168^1348920379^^^^0"Amb Referral to Orthopedic Surgery
Pending Review
HYPERLINK "epic:EPIC?REPORT&MR_REPORTS&11^R99#51038,EPT,%20Z12893168,54337"All Encounter Results
Medication Changes

None
HYPERLINK "javascript:void(0);"Medication List
Visit Diagnoses

Annual physical exam

Acute pain of right foot
HYPERLINK "javascript:void(0);"Problem List