This is a Patient resource. The patient's id is 39533e4a-f6f2-a144-ab37-6500460250dc. The patient's name is Juan Diaz. The patient's birthdate is 1971-12-14. The patient's administrative gender is male. The patient's race is Mexican, coded as 2150-1, using system urn:oid:2.16.840.1.113883.6.238. The patient's ethnicity is Hispanic or Latino, coded as 2186-5, using system urn:oid:2.16.840.1.113883.6.238. The patient's marital status is D, coded as D, using system http://terminology.hl7.org/CodeSystem/v3-MaritalStatus. The patient's social security number is 999-77-3224.


# Neurology Follow-up Note
Date: March 15, 2023
Provider: Dr. Sarah Chen, Neurologist
 
Patient: Juan Diaz, 51-year-old male 
 
CC: Follow-up for CVA (January 2023)
 
Subjective:
Patient reports continued improvement in left-sided weakness. He has been compliant with home exercises and aspirin regimen. Denies any new neurological symptoms. Reports some difficulty with fine motor tasks but is able to perform ADLs independently.
 
Objective:
- BP: 128/82, HR: 76, RR: 14, Temp: 98.6°F
- Neurological exam:
  - Cranial nerves intact
  - Motor strength: 4+/5 in left upper and lower extremities, 5/5 on right
  - Sensation intact bilaterally
  - Reflexes 2+ and symmetric
  - Gait: Minimal left-sided limp, but steady
 
Assessment:
1. Status post CVA with improving left hemiparesis
2. Hypertension, controlled
3. Type 2 Diabetes Mellitus
4. Obesity
5. Tobacco use
 
Plan:
1. Continue current medications including aspirin and statin
2. Follow up with primary care for diabetes and hypertension management
3. Strongly advised smoking cessation - provided resources
4. Continue home exercise program
5. Return to clinic in 3 months or sooner if symptoms worsen
 
==
 
# Primary Care Note
Date: August 10, 2023
Provider: Dr. Michael Johnson, Primary Care Physician
 
Patient: Juan Diaz, 51-year-old male 
 
CC: Follow-up for chronic conditions and job difficulty
 
Subjective:
Patient reports difficulty in maintaining his job as a farm worker in June due to inability to meet physical demands post-stroke. He admits to increased alcohol consumption (5-10 beers daily) since job loss. Denies suicidal ideation but expresses feelings of hopelessness. Reports compliance with diabetes and HTN medications.
 
Objective:
- BP: 138/88, HR: 82, RR: 16, Temp: 98.4°F, BMI: 34
- General: Alert, oriented, but appears distressed
- Cardiovascular: Regular rate and rhythm, no murmurs
- Respiratory: Clear to auscultation bilaterally
- Neurological: Residual mild left-sided weakness, otherwise intact
 
Labs:
- HbA1c: 7.8% (up from 7.2% 6 months ago)
- LFTs: Mildly elevated AST/ALT
 
Assessment:
1. Alcohol abuse
2. Diabetes Mellitus Type 2 - poor control
3. Hypertension - adequately controlled
4. Obesity
5. History of CVA
6. Tobacco use disorder
 
Plan:
1. Adjust metformin dose for better glycemic control
2. Counseled on alcohol cessation - referred to substance abuse program
3. Screened for depression - PHQ-9 score 14 (moderate depression)
4. Refer to vocational rehabilitation services
5. Follow up in 1 month
 
==
 
# Urgent Care Note
Date: September 22, 2023
Provider: Dr. Lisa Patel, Urgent Care Physician
 
Patient: Juan Diaz, 51-year-old male 
 
CC: Acute bronchitis
 
Subjective:
Patient presents with 5-day history of productive cough, low-grade fever, and fatigue. Denies shortness of breath or chest pain. Reports recent separation from wife and currently staying with a friend. Admits to continued alcohol use and smoking.
 
Objective:
- BP: 142/90, HR: 88, RR: 18, Temp: 99.8°F, O2 Sat: 97% on room air
- General: Fatigued appearance, frequent coughing
- HEENT: Mild pharyngeal erythema
- Respiratory: Rhonchi in bilateral lower lobes
- Cardiovascular: Regular rate and rhythm, no murmurs
 
Assessment:
1. Acute bronchitis
2. Hypertension - elevated
3. Alcohol abuse
4. Tobacco use disorder
5. Recent psychosocial stressors (job loss, marital separation)
 
Plan:
1. Prescribed azithromycin for bronchitis
2. Encouraged increased fluid intake and rest
3. Strongly advised smoking cessation and alcohol reduction
4. Recommended follow-up with primary care for blood pressure management and psychosocial issues
5. Provided information on VA support services for housing and substance abuse
 
==
 
# Social Work Consult Note
Date: October 18, 2023
Provider: Emily Rodriguez, LCSW
 
Patient: Juan Diaz, 51-year-old male 
 
Reason for Consult: Homelessness and psychosocial support
 
Subjective:
Patient referred by primary care for assistance with housing and support services. Reports becoming homeless this month following separation from wife. Currently alternating between staying at local shelters and with friends. Expresses feelings of hopelessness and admits to continued alcohol abuse (6-8 beers daily). Denies suicidal ideation.
 
Objective:
- Patient is alert and oriented, adequately groomed
- Mood appears depressed, affect flat
- No signs of acute intoxication during interview
 
Psychosocial Assessment:
- Housing: Currently homeless
- Employment: Unemployed since June 2023 (former postal carrier)
- Support system: Limited, recently separated from wife
- Substance use: Active alcohol abuse, long-term smoker
- Mental health: Symptoms of depression, no prior psychiatric history
 
Plan:
1. Provided information on homeless programs and assisted with application for HUD program
2. Referred to community substance abuse treatment program
3. Scheduled appointment with mental health services for depression evaluation
4. Provided resources for local food banks and daily meal programs
5. Discussed importance of maintaining medical appointments and medication compliance
6. Will follow up in 2 weeks to assess progress and provide additional support
 
==
 
# Emergency Department Note
Date: November 25, 2023
Provider: Dr. James Wilson, Emergency Medicine Physician
 
Patient: Juan Diaz, 51-year-old male 
 
CC: Fall with facial contusion
 
Subjective:
Patient presents after falling on sidewalk. Reports drinking "a few beers" prior to the fall. Denies loss of consciousness, headache, or vomiting. Admits to ongoing homelessness and alcohol use.
 
Objective:
- BP: 145/95, HR: 84, RR: 16, Temp: 98.2°F, O2 Sat: 99% on room air
- General: Smell of alcohol on breath, ambulatory with steady gait
- HEENT: 3 cm contusion on left forehead, no lacerations
- Neurological: PERRLA, no focal deficits, GCS 15
- Musculoskeletal: Full ROM in all extremities, no apparent fractures
 
Diagnostics:
- CT head: No acute intracranial abnormalities
 
Assessment:
1. Minor head contusion secondary to fall
2. Alcohol intoxication
3. Hypertension - elevated
4. Chronic conditions: Type 2 Diabetes, History of CVA, Obesity
 
Plan:
1. Head injury precautions reviewed
2. Advised on alcohol cessation and risks of continued use
3. Provided patient with information on VA substance abuse programs and homeless services
4. Recommended follow-up with primary care for hypertension management
5. Discharged in stable condition with friend who agreed to stay with patient