Name: Bob Kelly DOB: 5/3/57 Age: 60 Date: 6/14/17

Wt: 190lbs Ht: 72 inches Temp: 101 HR: 80 BP: 140/90

O2 Sat: n/a BMI: 25.8 LMP:n/a Normal Abnormal
Type of visit: New Pt. Physical Est. Pt Simple follow up
Interpreter: n/a

Chief Complaint:

HPI:

ROS: Check if Positive:

Gen: wt. loss wt. gain fever/chills fatigue/malaise denies all denies all others
Skin: rashes pruritus hair changes nail changes easy bruising dryness denies all
denies all others
Eye: vision changes (blurriness/diplopia) eye pain redness discharge itching photophobia
denies all denies all others
ENT: ear pain ear discharge hearing loss tinnitus loss of smell nasal discharge
nasal/sinus congestion sneezing pain or lesions in mouth sore throat
changes in voice or hoarseness denies all denies all others
CV: chest pain or tightness palpitations presyncope or syncope dyspnea at rest
dyspnea on exertion orthopnea paroxysmal nocturnal dyspnea peripheral edema
claudication denies all denies all others
PULM: dyspnea cough sputum production wheezing hemoptysis denies all
denies all others
GI: abdominal pain abdominal distention nausea vomiting diarrhea constipation
heartburn dysphagia odynophagia change in color/caliber of stool melena
bright red blood in stool jaundice denies all denies all others
GU: increased urinary frequency urinary urgency dysuria hematuria change in urine color
change in urine odor nocturia incontinence denies all denies all others
Female: vaginal discharge itching dryness genital lesions dyspareunia menstrual problems
menopausal symptoms breast pain breast mass nipple discharge denies all
denies all others
Male: urethral discharge penile lesions scrotal/testicular pain/swelling trouble starting urination
trouble stopping urination erectile dysfunction denies all denies all others
MSK: joint pain stiffness redness swelling neck pain back pain denies all
denies all others
Neuro: head trauma loss of consciousness headaches seizures focal numbness focal tingling
focal weakness difficulty w/speech difficulty w/understanding vertigo gain problems
coordination problems tremors concentration/memory problems denies all
denies all others
Psych: feeling down/depressed anxious irritable suicide ideation denies all denies all others

Physical Exam:
HEENT:
CV:
PULM:
Abd:
Genital:

Diagnostics (Labs/Imaging/Other):
UA: reveals many leukocytes

Assessment:
Acute Prostatitis
HTN

Plan:
How did we come to your diagnosis? Go into the patho of it.
How are we managing it with drugs? What is the MoA of the drug? Why did you pick this
drug over any other drug?
Directions for taking medication.
o When should symptoms improve?
o AEs of the medication. What can be done to decrease AEs.
o Do not take med with ___.
o Other counseling points.

Education:
Other:
Seek immediate medical attention if you begin to see blood in your urine or if your fever
persists, since you should begin to see symptom improvement in two days.
Seek immediate medical attention if you begin to feel confused or sense a change in your
mental status, or develop difficulty breathing,
Seek immediate medical attention if any of the above mentioned side effects become severe
or prolonged. Seek medical attention if your fever, difficulty urinating and rectal pain
become more severe or does not improve within one week.
Seek immediate attention if you experience allergic reaction symptoms, such as difficulty
breathing, closing of your airways, or any sort of rash.
Signature: Estelle Legros
Barriers to treatment: Comprehends meds Response to meds Education Self-care plan
Logs Lifestyle Mood
Name: Estelle Legros
Date: 6/14/17
Case: #5

Mercer Bear Family Practice, LLC

3001 Mercer University Dr.
Atlanta, GA 30341

John Doe, MD Phone: 555-555-5555

Mercer PA Student, PA-S

Name: Bob Kelly Date: 6/14/17

Address: 44 MyAddress Dr. DOB: 5/3/57

Atlanta, GA
30329

Ciprofloxacin 500mg
#56

Sig: 1 tablet PO BID Ciprofloxacin x 56 doses for Prostatitis

Refills: 0
May Substitute: Signature: Estelle Legros
Mercer PA Student, PA-S

Acute Bacterial Prostatitis Treatment & Management. Medscape.

http://emedicine.medscape.com/article/2002872-treatment . Accessed June 14,
2017.

Sikes, Martha. Urinary Tract Infections. [PowerPoint]. Atlanta, Ga: Mercer University
Physician Assistant Program ; 2017. Accessed June 14, 2017.