Outpatient Office Visit
Patient Case Number: OPOV- Thomas, Kanon (New)
Patient Name: Kanon Thomas | DOB: 01-02-60 | Sex: M
Date of Service: 07-01-XX | Physician: Richard Kelly, MD

# Chief Complaint: Needs to establish PCP. Dry cough x 5 months. Foot pain.

# History of Present Illness:

Mr. Thomas is being seen for an initial evaluation of his cough which has been present on and off for about 2 years. Rarely productive but states sometimes white phlegm. In past he had been treated for both asthma and seasonal allergies but has been out of medication for quite some time now. Also states the cough is worse at night when laying down and often has a sore/rough throat in the morning Associated symptoms include dyspnea, wheezing, runny nose, heartburn and painful swallowing, but no chills, no fever, no stuffy nose, no sore throat, no myalgias, no pleuritic chest pain, no chest pain, no vomiting, no postnasal drainage, no mouth breathing, no rapid breathing, no hoarseness, no eye itching, no nose itching, no headache, no hemoptysis and no night sweats.

Mr. Thomas also reports foot pain. He spends between 12-16 hours a day on his feet and has pain in both, R>L, for over a year now. Rest improves but weight bearing makes it worse. The pain is mainly in the heel area and is worst first thing in the morning with weight bearing. Ice helps to alleviate.

# Medical History: Asthma, GERD, seasonal allergies

# Allergy: NKDA

# Surgical History: Appendectomy

# Family History:

- Family history of cardiac disorder

- Family history of diabetes mellitus

- Family history of hypertension

- Family history of diabetes mellitus

# Medications: Flomax 0.4mg, Fluticasone 50 mcg/act, Myrbetriq 50mg, Naproxen 500mg, Omeprazole 20mg, Ventolin HFA 108 (90 base) mcg/act inhalation aerosol

# Review of Systems:

# Constitutional: no fever, no chills, no malaise and no fatigue.

# ENT: nasal congestion, sneezing, sore throat and scratchy throat, but no earache, no hearing loss, no nasal discharge and no hoarseness.

# Cardiovascular: negative.

# Respiratory: shortness of breath, wheezing and dry cough, but not sleeping upright or with extra pillows, no clear sputum, no

colored sputum and no coughing up blood.

# Gastrointestinal: abdominal pain, nausea and reflux, but no abdominal bloating, no abdominal cramps, no vomiting, no diarrhea, no

hematemesis, no constipation and no bright red blood per rectum. Genitourinary: urinary frequency and nocturia, but no urinary urgency and no urinary incontinence.

# Musculoskeletal: diffuse joint pain, joint swelling and joint stiffness, but no generalized muscle aches, no back pain and no back

muscle spasm.

# Vitals: Temp-98.7, HR 70, Resp-18, BP 128/38, Height 5’9”, Weight-215lbs, BMI-31.8

# Physical Exam Constitutional

# General appearance: Abnormal. well developed, comfortable, well nourished, obese

and rested.

# Ears, Nose, Mouth, and Throat: External inspection of ears and nose: Normal. Oropharynx: Normal. Nasal mucosa, septum, and turbinates: Normal.

# Pulmonary: Respiratory effort: Normal. Auscultation of lungs: Normal. Cardiovascular: Palpation of heart: Normal. Auscultation of heart: Normal. Examination of extremities for edema and/or varicosities: Normal.

# Abdomen: Normal. Liver and spleen: Normal.

# Musculoskeletal: Gait and station: Normal. Digits and nails: Normal. Inspection/palpation of joints, bones, and muscles: Normal.

# Skin: Skin and subcutaneous tissue: Normal.

# Neurologic Cranial nerves: Normal. Sensation: Normal.

# Psychiatric: Orientation to person, place, and time: Normal. Mood and affect: Normal.

# Assessment/Plan:

1. Mild intermittent asthma-start Ventolin HFA 108-inhale one puff every four hours as needed

2. Gastroesophageal reflux disease without esophagitis-start Omeprazole 20mg oral tablet, take one capsule daily as needed

3. Seasonal allergic rhinitis-start Fluticasone 50mcg/act, use one spray in each nostril once daily

4. Chronic foot pain, right-start Naproxen 500mg oral tablet, take one tablet every 12 hours as needed

# Electronically Signed By: Richard Kelly, MD

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