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                    CLINICAL OUTPATIENT ENCOUNTER NOTE
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PATIENT INFORMATION
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Patient Name:       Doe, Jane
MRN:                9482104
DOB:                04/12/1978 (Age: 48)
Date of Service:    09/18/2026
Encounter Type:     Outpatient Internal Medicine / Routine Follow-up
Attending Provider: Dr. Alex Mercer, MD, FACP
Clinic Location:    Metro Health Center, Suite 400

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SUBJECTIVE
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CHIEF COMPLAINT:
"Here for a regular blood pressure check and to talk about some knee stiffness."

HISTORY OF PRESENT ILLNESS (HPI):
Jane Doe is a 48-year-old female with an established medical history of 
essential hypertension and mild bilateral knee osteoarthritis who presents 
for a routine 6-month chronic care follow-up.

1. Essential Hypertension:
   - Patient reports strict compliance with daily Lisinopril (10 mg PO once daily).
   - Home blood pressure logs indicate consistent control, averaging 125-135 
     mmHg systolic and 75-85 mmHg diastolic, without isolated systolic or 
     diastolic spikes exceeding 140/90 mmHg.
   - Denies headache, lightheadedness, syncope, visual changes, chest pain, 
     shortness of breath, orthopnea, or lower extremity edema.

2. Musculoskeletal (Knees):
   - Reports gradual, mild bilateral knee stiffness, predominantly when rising 
     from a seated position after prolonged desk work and when ascending stairs.
   - Stiffness improves after 10-15 minutes of light ambulation.
   - Denies focal swelling, joint locking, instability, or acute trauma.
   - Symptoms managed intermittently with OTC acetaminophen with satisfactory 
     relief.

CURRENT MEDICATIONS:
1. Lisinopril 10 mg oral tablet; take 1 tablet daily by mouth.
2. Acetaminophen 500 mg oral tablet; take 1-2 tablets PRN joint discomfort 
   (reported usage: 1-2 times per week).
3. Multivitamin adult oral tablet; 1 tablet daily.

ALLERGIES:
- Penicillin (Reaction: mild cutaneous maculopapular rash; no airway compromise 
  or anaphylaxis).

PAST MEDICAL HISTORY:
- Essential Hypertension (ICD-10: I10), diagnosed 2021
- Primary Osteoarthritis, bilateral knees (ICD-10: M17.0), diagnosed 2023

PAST SURGICAL HISTORY:
- Appendectomy (laparoscopic), 2012; uncomplicated.

SOCIAL HISTORY:
- Tobacco: Lifetime non-smoker.
- Alcohol: Rare/moderate (1-2 glasses of wine on weekends; approx. 2 standard 
  drinks/week).
- Illicit Drugs: None.
- Exercise: 30 minutes of brisk walking 3-4 days per week.
- Occupation: Administrative coordinator (sedentary work).

FAMILY HISTORY:
- Father: Deceased at 74 (Myocardial infarction).
- Mother: Alive at 71 (Type 2 diabetes mellitus, hypertension).
- Siblings: One younger brother, healthy.

REVIEW OF SYSTEMS (ROS):
- Constitutional: No fatigue, unintended weight changes, fever, or chills.
- Eyes: No vision blurriness or eye pain.
- Cardiovascular: No palpitations, chest pressure, or orthopnea.
- Respiratory: No dyspnea, wheezing, or chronic cough.
- Gastrointestinal: No nausea, vomiting, abdominal pain, or changes in bowel habits.
- Musculoskeletal: Positive for mild knee stiffness as per HPI; negative for 
  generalized arthralgias or myalgias.
- Neurological: No focal weakness, paresthesias, or dizziness.
- Psychiatric: Normal mood; denies sleep disturbances or elevated anxiety.

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OBJECTIVE
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VITAL SIGNS:
- Blood Pressure:       128/82 mmHg (Right arm, regular adult cuff, seated)
- Pulse Rate:           72 bpm (regular rate and rhythm)
- Respiratory Rate:     16 breaths/min (unlabored)
- Body Temperature:     98.4 deg F (36.9 deg C, oral)
- SpO2:                 99% on room air
- Height:               5 ft 6 in (167.6 cm)
- Weight:               164 lbs (74.4 kg)
- BMI:                  26.4 kg/m^2

PHYSICAL EXAMINATION:
- General: Well-appearing, well-nourished female, awake, alert, oriented x4. 
  In no acute distress.
- Eyes: Sclerae anicteric; conjunctivae pink; PERRL.
- Head/Neck: Normocephalic, atraumatic. Supple neck, no jugular venous 
  distension (JVD), no carotid bruits.
- Cardiovascular: Regular rate and rhythm. Distinct S1 and S2 present. No 
  audible murmurs, gallops, or friction rubs. Distal pulses (radial and DP) 
  intact and 2+ bilaterally.
- Pulmonary: Lungs clear to auscultation bilaterally (CTAB). Good air exchange. 
  No crackles, wheezing, or rhonchi.
- Abdomen: Soft, non-tender, non-distended. Bowel sounds normoactive across all 
  4 quadrants. No hepatomegaly, splenomegaly, or palpable masses.
- Musculoskeletal: Normal gait and station. Bilateral knees demonstrate full 
  active and passive range of motion (0-135 degrees). Mild bilateral 
  patellofemoral crepitus noted with movement. No joint line tenderness, 
  warmth, erythema, or joint effusion bilaterally. Anterior/posterior drawer 
  and varus/valgus stress maneuvers stable.
- Extremities: Warm and well-perfused. Trace/no edema in lower extremities.
- Neurologic: Grossly non-focal. Cranial nerves II-XII intact. Sensation intact 
  to light touch throughout lower extremities.

LABORATORY & DIAGNOSTIC REVIEW:
Basic Metabolic Panel (BMP) - Fasting (Drawn 09/15/2026):
- Sodium:               140 mEq/L       (Ref: 135-145 mEq/L)
- Potassium:            4.3 mEq/L       (Ref: 3.5-5.0 mEq/L)
- Chloride:             102 mEq/L       (Ref: 98-107 mEq/L)
- CO2:                  24 mEq/L        (Ref: 22-29 mEq/L)
- Blood Urea Nitrogen:  14 mg/dL        (Ref: 7-20 mg/dL)
- Serum Creatinine:     0.85 mg/dL      (Ref: 0.50-1.10 mg/dL)
- eGFR:                 >90 mL/min/1.73m^2
- Fasting Glucose:      94 mg/dL        (Ref: 70-99 mg/dL)
Impression: Normal renal function and electrolyte balance on ACE-inhibitor therapy.

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ASSESSMENT & PLAN
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SUMMARY:
48-year-old female presenting for routine follow-up with well-controlled primary 
hypertension on lisinopril and stable, mild bilateral knee osteoarthritis.

1. Essential Hypertension (ICD-10: I10):
   - Current Status: Controlled. Office BP 128/82 mmHg; recent home averages 
     concordant. Serum creatinine and potassium levels are unremarkable.
   - Plan:
     * Continue Lisinopril 10 mg PO once daily.
     * Refilled 90-day supply with 3 refills sent electronically to preferred 
       pharmacy.
     * Continue periodic home BP logs (recommend 2-3 measurements weekly).
     * Re-emphasized dietary salt reduction (DASH diet) and routine physical 
       activity.

2. Primary Bilateral Knee Osteoarthritis (ICD-10: M17.0):
   - Current Status: Stable, mild symptoms without acute joint instability or 
     effusion.
   - Plan:
     * Continue conservative symptom management. Continue acetaminophen 500 mg 
       PRN (instructed not to exceed 2000-3000 mg within 24 hours).
     * Recommended incorporation of low-impact quadriceps-strengthening exercises 
       (e.g., stationary cycling, water aerobics) to support joint mechanics.
     * Patient was advised to contact clinic for formal physical therapy 
       referral if functional impairment or pain increases.

3. Preventive Medicine & Health Maintenance:
   - Annual influenza vaccine offered and administered in clinic today (Lot #FL8842, 
     Deltoid Left, Exp: 05/2027).
   - Fasting lipid panel and mammogram due for scheduling at upcoming annual exam.

DISPOSITION & FOLLOW-UP:
- Follow-up in clinic in 6 months for scheduled hypertension check and repeat 
  routine metabolic labs.
- Return sooner or seek urgent medical evaluation if severe headache, chest 
  discomfort, acute dyspnea, or sudden joint swelling/inability to bear weight occurs.

Time spent in encounter: 25 minutes (greater than 50% devoted to chronic disease 
management and counseling).

Electronically Signed:
Alex Mercer, MD, FACP
License #: MD-882310
Date/Time: 09/18/2026 08:15 MDT
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