SUBJECTIVE
Patient for hyperlipidemia clinic. He is due to be released at any time. He states they cannot find a place for him to go, he was supposed to have been released a few weeks ago but it should be coming up soon. In any event, one complaint he has, he states that he swallowed something a week ago and he feels like there is something stuck in his throat. He says he cannot clear it. Denies any nausea, vomiting, diarrhea, fever. Does not cause any choking. He is not coughing while I am visiting with him at this time. He has a history of a CVA also, this was a left-sided hemiplegia that he has. This was back in 2009. He was here with us quite a few years. I believe he was gone for quite some time, I think over a year but came back to us at this time and is due to be leaving again. In the meantime, I reviewed all his labs. All his labs were done about in 2013, so he needs a full update on these, which I will do. Other than that, HEENT was within normal limits. No cervical adenopathy was noted. Pulmonary was clear all fields. Cardiovascular was just slightly tachy. No lower extremity edema noted. Again, reviewed his labs. Cholesterol was good. His last cholesterol lab was four years ago. Total cholesterol was in the 170s, so again he needs a new lab …show more content…
For labs will get a CBC, CMP, lipid panel, Hemoccults x3, and a PSA, and I will get an x-ray of the neck area so we can try to visualize the esophagus and the tracheal area and try to see if there is anything causing this globus sensation and will continue to monitor him at this time. Patient agrees with plan. I also failed to mention, he was complaining of increased frequency of urination, it has been going on for years at nighttime. He states sometimes at night six times he goes to bathroom. I am going to start him on some Flomax 0.4 mg at nighttime. Patient agrees with this plan. We will continue to monitor him at this
Patient for hyperlipidemia clinic. He is due to be released at any time. He states they cannot find a place for him to go, he was supposed to have been released a few weeks ago but it should be coming up soon. In any event, one complaint he has, he states that he swallowed something a week ago and he feels like there is something stuck in his throat. He says he cannot clear it. Denies any nausea, vomiting, diarrhea, fever. Does not cause any choking. He is not coughing while I am visiting with him at this time. He has a history of a CVA also, this was a left-sided hemiplegia that he has. This was back in 2009. He was here with us quite a few years. I believe he was gone for quite some time, I think over a year but came back to us at this time and is due to be leaving again. In the meantime, I reviewed all his labs. All his labs were done about in 2013, so he needs a full update on these, which I will do. Other than that, HEENT was within normal limits. No cervical adenopathy was noted. Pulmonary was clear all fields. Cardiovascular was just slightly tachy. No lower extremity edema noted. Again, reviewed his labs. Cholesterol was good. His last cholesterol lab was four years ago. Total cholesterol was in the 170s, so again he needs a new lab …show more content…
For labs will get a CBC, CMP, lipid panel, Hemoccults x3, and a PSA, and I will get an x-ray of the neck area so we can try to visualize the esophagus and the tracheal area and try to see if there is anything causing this globus sensation and will continue to monitor him at this time. Patient agrees with plan. I also failed to mention, he was complaining of increased frequency of urination, it has been going on for years at nighttime. He states sometimes at night six times he goes to bathroom. I am going to start him on some Flomax 0.4 mg at nighttime. Patient agrees with this plan. We will continue to monitor him at this