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Regards,

Dr. Braedon Hendy

SPatient presents with abdominal pain for the past «Duration». «Location», «Character», alleviated with «», provoked with «», «Radiating», «Timing», «Severity». «No» nausea, vomiting, fever, diarrhea, constipation, weight loss, or trauma. «No» melena or hematochezia. «No» recent travel or sick contacts. «No» urinary symptoms or discharge. «LMP». Last pap «».

OGen - NAD. No jaundice or pallor VS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no masses, no organomegaly. Neg McBurney/Psoas/Obturator/Rovsing/Murphy/Rebound BACK - no CVA TTP«Urinalysis and Pregnancy Test»

AAbdominal pain, query «»

PBlood work for extended lytes, creatinine, LFT, CBC, HbA1c, lipaseAXRAbdominal ultrasoundRTC or go to the ER if pain acutely worsensRe-assess if no improvement in «»

SPatient presents for spontaneous abortion. «Obstetrical history». LMP «». Last pap «». Cramping and vaginal bleeding noted. «No» nausea, vomiting, fever, or trauma.

OGen - NAD. No jaundice or pallorVS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses, no organomegaly

ASpontaneous abortion, «» controlled

P«Counselling»Bloodwork for CBC, group and screen, and B-HCG«Pelvic ultrasound»«Misoprostol 800 mcg vaginally»«Mifepristone 200 mg PO and misoprostol 800 mg bucally 48 hours later if TA < 70 days LMP and no signs of ectopic pregnancy»«Rhogam 120 mcg (<12 weeks) or 300 mcg (>12 weeks) if Rh negative»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess in «»

SPatient presents for follow-up of acne. Alleviated with «» and provoked with «».

OGen - NADVS - «»DERM - Grade «» lesions seen on the «». Scarring is «not» present.

AAcne vulgaris

PAvoid scrubs, shave with grain, d/c thick moisturizers and make-upOnce daily mild cleanser is recommended with pregnant patients«Adapalene applied initially q2-3 days until tolerated, then daily»«TactuPump applied initially q2-3 days until tolerated, then daily»«Yaz to be initiated»«Minocycline 100 mg daily for 90 days»«Isotretinoin and signed contract with pregnancy test, 2 forms of contraception, and monitor CBC/LFT/Lipids at 0/1/3 months»Side effects discussedRe-assess in «»

SPatient presents for follow-up of ADHD. Difficulty to control and affects daily living. Alleviated with «» and provoked with «». «Home and school history». No FH of cardiac disorders.

OGen - NAD VS - «»CVS - S1, S2, RRR, no MRG«ADHD questionnaire»

AADHD, query «»

PParent training with schedules«Aderall XR»«Concerta»«Biphentin»«Vyvanse» PO daily Side effects discussedRTC or go to ER if symptoms acutely worsenRe-assess in «»

SPatient presents with allergies for the past «Duration». Alleviated with «» and provoked with «».

OGen - NADVS - «»HEENT - conjunctiva and nasopharynx clearCVS - S1, S2, RRR, no MRGRESP - CTAB

AAllergic rhinitis, «» controlled

PAvoidance of sources including changing filters and bed covers«Avamys 27.5 mcg 2 sprays per nostril daily»«Pataday 0.2 % to be applied daily»«Cetirizine 20 mg PO daily»Side effects discussedRTC or go to ER if symptoms acutely worsenRe-assess in «»

SPatient presents with amenorrhea for the past «Duration». «Menstrual history». «Obstetrical history». «Eating history». LMP «». Last pap «»

OGen - NAD. No clinical signs of hyperandrogenismVS - «»HEENT - thyroid normal appearance with no masses or bruitsCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no masses, no organomegalyDERM - no nail, hair, or skin changes«Pregnancy Test»

AAmenorrhea, query «»

PBlood work for HCG, LH, FSH, estradiol, testosterone, TSH, prolactinPelvic ultrasoundRe-assess in «»

SPatient presents for follow-up of anemia. «No» nausea, vomiting, fever, diarrhea, constipation weight loss, or trauma. «No» hemoptysis, hematuria, melena, or hematochezia. «Menstrual history». «Diet history».

OGen - NAD. No jaundice or pallor notedVS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no masses, no organomegalyDERM - no nail, hair, or skin changes

AAnemia, query «»

PBlood work for «based on MCV and findings»RTC or go to the ER if fatigue worsens or experiencing SOBRe-assess in «»

SPatient presents with an animal bite that occurred «Duration». «Description of animal and if provoked»

OGen - NAD. No jaundice or pallor notedVS - «»EXT - «Description of function and neurovascularly intact»DERM - «»

Procedure - «local anesthetic with irrigation, debridement, and removal of any foreign bodies with no suturing»

AAnimal bite, «» controlled

PReport to Public Health«Tetanus prophylaxis»«Rabies prophylaxis»«Imaging»«Clavulin 875 mg PO BID for 10 days»Side effects discussedRTC or go to the ER if signs of infection or bleeding

SPatient presents with anxiety for the past «Duration». Difficulty to control and affects daily living. Alleviated with «» and provoked with «». «Smoking, ETOH, drug, and caffeine history». No panic-like episodes. Denies SI/HI. Denies manic episodes or hallucinations. «No» history of abuse or trauma. «No» family history of mental health disorders. «FIFERS»

OGen - NAD with «» eye contactVS - «»Appearance - «»Speech - «»Mood - «»Affect - «»CVS - S1, S2, RRR, no MRGRESP - CTAB«GAD7 and PHQ9»

AAnxiety, query «»

PBlood work for CBC, TSH, electrolytes, and urine drug screenECG Meditation, breathing techniques, goal setting, and MoodgymCipralex titrated to 10 mg PO daily with side effects discussedVerbally contracted for safety; if the patient is experiencing SI/HI, they are to RTC, contact crisis (5199734435), or go to the ERRe-assess in «»

Time «»

SPatient presents for follow-up of asthma. Alleviated with «» and provoked with «». «No» noted wheezing or nocturnal cough. «» day-time/night-time symptoms per week. Denies worsening with exercise or missed activities. Has «not» been hospitalized for asthma exacerbation. «No» history of atopy. Diagnosed by «». UTD with immunizations.

OGen - NAD. No central or peripheral cyanosis VS - «»CVS - S1, S2, RRR, no MRGRESP - CTAB with no nasal flaring, tracheal tug, intercostal indrawing, or accessory muscle use

AAsthma, «» controlled

PTrigger avoidancePeak flow meterAsthma action planAsthma education referralUse of age-appropriate spacerRTC or go to the ER as described in asthma action planRe-assess in «»

SPatient presents for follow-up of atrial fibrillation. «No» substernal discomfort that is alleviated with «» and provoked with «». «No» palpitations, dyspnea, or syncope.

OGen - NAD. No central or peripheral cyanosisVS - «»HEENT - thyroid normal appearance. No JVDCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance, soft, NT, ND, no bruits, no masses, no organomegaly. EXT - no edema CHADS2 risk - «»HASBLED risk - «»

AAtrial fibrillation, «» controlled

PBlood work for lytes, creatinine, TSH, LFT, CBC, HbA1c, PTT, INR, and lipid panelCXRECGEchoSleep studyStress testManage contributing conditionsHealthy lifestyle including weight loss, limited fluid and salt intake, Mediterranean diet, and supervised cardiac rehabilitation «Bisoprolol 2.5 mg PO daily»«ASA 81 mg PO daily»«Apixiban 5 mg BID»«Warfarin 5 mg PO daily with INR q48 hours for mechanical heart valves, mitral valve stenosis, and CKD with bridging if at high risk of thromboembolism»Side effects discussedRTC or go to the ER is symptoms acutely worsenRe-assess in «»

SPatient presents with back pain for the past «Duration». «Location», «Character», alleviated with «», provoked with «», «Radiating», «Timing», «Severity». «No» incontinence, saddle anesthesia, parathesias, weakness, weight loss, or trauma.

OGen - NAD. No jaundice or pallor VS - «»ABD - normal appearance and BS, soft, NT, ND, no bruits, no masses BACK - TTP at «» with full ROMEXT - neurovascularly intact with +2 DTR b/l. Neg straight leg test. Normal plantar reflex

ABack pain, query «»

PContinue to stay active and return to work when ableAppropriate back and neck supportHeat wrapPhysiotherapy, chiropractor, and massage therapy«LS X-ray greater than 4 weeks vs. MRI for radicular symptoms»«Acetaminophen 1000 mg PO QID PRN»«Naproxen 500 mg PO BID PRN»«Flexeril 10 mg PO TID PRN»«Amitriptyline 10 mg PO qHS»Side effects discussedRTC or go to the ER if pain does not resolve or acutely worsensRe-assess if no improvement in «»

SPatient presents for follow-up of BPH. Alleviated with «» and provoked with «». «No» dysuria, frequency, urgency, nocturia, hesitancy, incontinence, incomplete void, nocturia, or erectile dysfunction. «No» B-type symptoms. Diagnosed by «».

OGen - NAD. No jaundice or pallor VS - «»ABD - normal appearance, soft, NT, ND, no masses BACK - no CVA TTPGEN - normal appearanceDRE - prostate normal size with no masses or TTP«Urinalysis»

ABPH, «» controlled

PFluid restriction, timed voiding, and ETOH and coffee avoidance«Blood work for lytes, creatinine, CBC, and PSA»«Urinalysis»«Post-void residual»«Tamsulosin 0.4 mg PO daily»«Tadalafil 10 mg PO daily»«Finasteride 5 mg PO daily»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess in «»

SPatient presents with a breast lump for the past «Duration». «Location». «No» changes in size during menstrual cycle, skin changes, nipple discharge/inversion, or TTP. «No» B-type symptoms. No family history of breast cancer.

OGen - NAD. No jaundice or pallorVS - «»Chest - breast symmetrical in appearance with no skin changes or nipple inversion/discharge noted with «» in the room. «Description of mass». No supraclavicular or axillary lymphadenopathy present

ABreast mass, query «»

PBreast ultrasound and mammogramRe-assess if no improvement in «»

SPatient presents with a thermal burn that occurred «Duration». «Description of how burn occurred».

OGen - NAD. No jaundice or pallor notedVS - «»EXT - «Description of function and neurovascularly intact»DERM - «»

AThermal burn, «» controlled

PCool compressesWound care«Tetanus prophylaxis»OTC NSAID«Flamazine to be applied as directed»Side effects discussedRTC or go to the ER if signs of infectionRe-assess if no improvement in «»

SPatient presents for follow-up of CAD. «No» substernal discomfort that is alleviated with «» and provoked with «». «No» palpitations or dyspnea.

OGen - NAD. No central or peripheral cyanosisVS - «»HEENT - No JVDCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance, soft, NT, ND, no bruits, no masses, no organomegaly. EXT - no edema

ACAD, «» controlled

PBlood work for lytes, creatinine, TSH, LFT, CBC, HbA1c, and lipid panelCXRECGEchoManage contributing conditionsHealthy lifestyle including weight loss, limited fluid and salt intake, Mediterranean diet, and supervised cardiac rehabilitation «ASA 81 mg PO daily»«Atorvastatin 40 mg PO qHS»«Perindopril 4 mg PO daily»«Bisoprolol 2.5 mg PO daily»«Nitro 1 spray SL q5min x 3; if not resolved go to the ER»Side effects discussedRTC or go to the ER is symptoms acutely worsenRe-assess in «»

SPatient presents with chest pain for the past «Duration». «Location», «Character», alleviated with «», provoked with «», «Radiating», «Timing», «Rule out sending to ER». «MSK symptoms». «GERD symptoms». «No» cough, dyspnea, or trauma reported. «Non»smoker.

OGen - NAD. No central or peripheral cyanosis VS - «»Chest - no TTP CVS - S1, S2, RRR, no MRGRESP - CTAB

AChest pain, query «»

PBlood work for «»CXRECGCardiac stress test (based on risk factor)«ASA 81 mg PO daily»«Nitro 1 spray SL q5min x 3; if not resolved go to the ER»Side effects discussedRe-assess if no improvement in «»

SPatient presents for follow-up of CHF. Reports fatigue, cough, PND, abdominal distension, and lower extremity edema. «No» CP. Dyspnea with «» blocks or «» flights of stairs. Has «not» been hospitalized for CHF exacerbation.

OGen - NAD. No central or peripheral cyanosisVS - «»HEENT - no JVDCVS - S1, S2, RRR, no MRGRESP - CTAB ABD - normal appearance, soft, NT, ND, no bruits, no masses, no organomegaly. EXT - no edema

ACHF stage «», «» controlled

PBlood work for lytes, creatinine, TSH, LFT, CBC, HbA1c, and lipid panelUrinalysisCXRECGEchoManage contributing conditionsHealthy lifestyle including weight loss, limited fluid and salt intake, Mediterranean diet, and supervised cardiac rehabilitation «Perindopril 4 mg PO daily»«Bisoprolol 2.5 mg PO daily»«Eplerenone 25 mg PO daily»«Furosemide 20-40 mg PO daily»«Metolazone 2.5 mg PO daily»Side effects discussedRTC or go to the ER is symptoms acutely worsenRe-assess in «»

SPatient presents for follow-up of CKD. Previously completed outpatient testing and GFR was «».

OGen - NAD. No pallor or jaundiceVS - «»HEENT - no JVDCVS - S1, S2, RRR, no MRGRESP - CTAB ABD - normal appearance and BS, soft, NT, ND, no bruits, no masses EXT - no edema

AChronic kidney disease, «» controlled

PLifestyle modifications including Mediterranean diet, decreased ETOH, weight loss, exercise, and smoking cessationBlood work for extended lytes, creatinine, ACR, CBC, HbA1c, and lipid panelUrinalysisKUB ultrasoundManage contributing conditions«Coversyl 4 mg PO daily if proteinuria and GFR > 30»Side effects discussedRTC or go to the ER if CP or dyspneaRe-assess in «»

SPatient presents with concussion-like symptoms that occurred «Duration». «No» history of previous concussions. «No» LOC, vomiting, neck pain, or amnesia. Complaining of «physical, emotional, cognitive, and sleep disturbances».

OGen - NAD. No jaundice or pallor VS - «»GCS - «»HEENT - NCAT. EOMI and PERRLA. Nasopharynx, tym mem, and oropharynx are clearNeck - full ROM with no midline TTPCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no masses EXT - gross motor strength and neurovascularly intactNEURO - CN2-12 intact with no cerebellar deficits. No tremor and gait normal

AConcussion, «»

P«MRI of head»Return to Play/Work GuidelineBESS testing when at baselineDiscussion of continuation of high-impact sportRTC or go to the ER if symptoms acutely worsen while monitoring for 48 hoursRe-assess if no improvement in «»

SPatient is here for contraception. «Partners, Practices, Protection, Previous STI, Pregnancy». «LMP». Last pap «». «No» migraine with auras, vascular disease, smoking, cancer, liver disease, abnormal vaginal bleeding, or post-partum.

OGen - NAD. No jaundice or pallor VS - «»«Pregnancy Test»

AContraception, «no» contraindications

PSafe sex practices including barrier protection and avoidance of ETOH/drugsVarious types of contraception discussed«Yaz/Alesse/Loestrin 28 to be started first Sunday of menses»«Micronor to be taken daily when breast feeding»Missed Micronor > 3 hours is to continue with pack as directed with barrier method for 48 hoursMissed Alesse in week 1 is to continue with pack as directed with barrier method for 7 days Missed Alesse in weeks 2/3 is to omit the hormone-free interval with barrier method for 7 days«Ulipristal acetate 30 mg PO within 5 days of unprotected intercourse with initiation of OCP and barrier method for 14 days»Side effects discussedRe-assess in «»

SPatient presents for follow-up of COPD. «Current» smoker with a «» pack year history. Is «not» on supplemental oxygen. Dyspnea with «» blocks or «» flights of stairs. Has «not» been hospitalized for COPD exacerbation. Last PFT «». UTD with immunizations.

OGen - NAD. No central or peripheral cyanosisVS - «»CVS - S1, S2, RRR, no MRGRESP - CTAB with no nasal flaring, tracheal tug, intercostal indrawing, or accessory muscle use

ACOPD, «» controlled

PSmoking cessationPeak flow meterPulmonary rehabilitation«Ventolin 1-2 puffs q4-6 hr PRN»«Spiriva 18 mcg inhaled daily»Side effects discussedRTC or go to the ER as described in COPD action planRe-assess in «»

SPatient presents with a cough for the past «Duration». «Non»productive and «no» wheezing. «No» nausea, vomiting, fever, diarrhea, or rashes. «No» recent travel or sick contacts. UTD with immunizations. «Non»smoker.

OGen - NAD. No jaundice or pallor VS - «»HEENT - oropharynx, nasopharynx, and tym mem clear. No cervical lymphadenopathyCVS - S1, S2, RRR, no MRGRESP - CTAB with no nasal flaring, tracheal tug, intercostal indrawing, or accessory muscle use noted

ACough, query «»

P«»Adequate hydrationOTC NSAID«CXR»«Echinacea and zinc lozenges»«Ratio-cotridin 10 mL PO TID PRN»«Z-pak if uncomplicated pneumonia»«Levofloxacin 750 mg PO daily for 5 days if complicated pneumonia»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with a cough for the past «Duration». «Non»productive and «no» wheezing. «No» nausea, vomiting, fever, diarrhea, or rashes. «No» recent travel or sick contacts. Good appetite. Good fluid intake and urinating. UTD with immunizations.

OGen - NAD. No clinical signs of cyanosis, dehydration, or lethargyVS - «»HEENT - oropharynx, nasopharynx, and tym mem clear. No cervical lymphadenopathy notedCVS - S1, S2, RRR, no MRGRESP - CTAB with no nasal flaring, tracheal tug, intercostal indrawing, or accessory muscle use notedABD - normal appearance and BS, soft, NT, ND, no masses DERM - no skin changesMcIsaac score - «»Strep test - «»

ACough, query «»

PHoney (>1 yr old), nasal suctioning, and humidified air to be given for comfortAdequate hydrationOTC NSAID for comfort«CXR»«Ventolin 1-2 puffs q4-6 hr PRN»«Dexamethasone 0.6 mg/kg PO x 1 (max 10 mg)»«Amoxicillin 80 mg/kg divided BID for 10 days (max 3 g)»Side effects discussedRTC or go to the ER if clinical signs of dehydration or lethargyRe-assess if no improvement in «»

SPatient presents with depression for the past «Duration». Difficulty to control and affects daily living. Alleviated with «» and provoked with «». «Smoking, ETOH, drug, and caffeine history». Denies SI/HI or previous attempts at self harm. Denies manic episodes or hallucinations. «No» history of abuse or trauma. «No» family history of mental health disorders. «FIFERS»

OGen - NAD with «» eye contactVS - «»Appearance - «»Speech - «»Mood - «»Affect - «»CVS - S1, S2, RRR, no MRGRESP - CTAB«GAD7 and PHQ9»

ADepression, query «»

PBlood work for CBC, TSH, electrolytes, and urine drug screenECG Meditation, breathing techniques, goal setting, and MoodgymCipralex titrated to 10 mg PO daily with side effects discussedVerbally contracted for safety; if the patient is experiencing SI/HI, they are to RTC, contact crisis (5199734435), or go to the ERRe-assess in «»

Time «»

SPatient presents with diarrhea for the past «Duration». Has experienced «» number of bowel movements daily. Alleviated with «» and provoked with «». «No» nausea, vomiting, fever, abdominal pain, weight loss, or trauma. «No» melena or hematochezia. «No» recent travel, sick contacts, or food outbreaks.

OGen - NAD. No jaundice or pallor. No clinical signs of dehydrationVS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses DERM - no skin changes

ADiarrhea, query «»

PAdequate hydrationBRAT dietBlood work for extended lytes, creatinine, LFT, CBC, TSH, CRP, ESR«Anti-TTG and IgA»«Stool cultures including C. difficile»«Colonoscopy»«Loperamide 4 mg initially and 2 mg after each loose BM if no blood or fever»«Ciprofloxacin 500 mg PO BID x 3 days if significant symptoms»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with dizziness for the past «Duration». Alleviated with «» and provoked with «». «Vertiginous»«Light-headed» description. «No» previous episodes. «No» headache, nausea, vomiting, fever, seizures, hearing loss, tinnitus, aural fullness, CP, dyspnea, palpitations, LOC, weakness, or recent infections.

OGen - NAD. No jaundice or pallor VS - «Seated and standing BP»HEENT - EOMI and PERRLA. Nasopharynx, tym mem, and oropharynx are clear. No carotid bruitCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses EXT - gross motor strength 5/5 with full ROM and sensation intactNEURO - CN2-12 intact with no cerebellar deficits. No tremor and gait normal. Dix-Hallpike maneuver negative

ADizziness, query «»

P«Blood work for extended lytes, creatinine, CBC, HbA1c, and TSH»«Epley maneuver performed with patient noting significant relief»«ECG»«Holter monitor»«Echocardiogram»«MRI of head»«Brandt-Daroff exercise sheet»«Betahistine 24 mg PO BID PRN»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents for follow-up of dyslipidemia. Non-smoker with no FH of CVD. Denies CP or dyspnea

OGen - NADVS - «»CVS - S1, S2, RRR, no MRGFramingham risk - «»

ADyslipidemia, «» controlled

PLifestyle modifications including Mediterranean diet, decreased ETOH, weight loss, exercise, and smoking cessation«Atorvastatin 20/40 mg PO qHS»«Ezetimibe 10 mg PO daily»Side effects discussedRe-assess in «»

SPatient presents with dysmenorrhea for the past «Duration». «Menstrual history». «Obstetrical history». LMP «». Last pap «». «No» nausea, vomiting, fever, dyschezia, dysparenuia, or trauma. «No» urinary symptoms or discharge.

OGen - NAD. No clinical signs of hyperandrogenismVS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses, no organomegaly«Urinalysis and Pregnancy Test»

ADysmemorrhea, query «»

P«Pelvic ultrasound»«Naproxen 500 mg PO BID PRN»«Mefenamic acid 500 mg loading dose and 250 mg PO q6hr PRN»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with dysuria for the past «Duration». «Character», alleviated with «», provoked with «», «Radiating», «Timing», «Severity». Increased frequency noted. «No» nausea, vomiting, fever, abdominal pain, incontinence, or flank pain. «No» hematuria. «No» recent new sexual partners. «No» vaginal discharge. Last UTI was «». LMP «». Last pap «».

OGen - NAD. No jaundice or pallor. No clinical signs of dehydration VS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance, soft, NT, ND, no masses BACK - no CVA TTP«Urinalysis and Pregnancy Test»

ADysuria, query «»

P«Blood work for extended lytes, creatinine, CBC»«Urine culture»«VCUG and KUB ultrasound if pyelonephritis, pediatric male, or female < 3 years old»«Septra DS 1 tab PO BID x 3 days for uncomplicated UTI»«Macrobid 1 tab PO BID x 5 days for pregnancy»«Ciprofloxacin 500 mg PO BID x 7 days for complicated UTI»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with an earache for the past «Duration». Alleviated with «» and provoked with «». «URTI symptoms». «No» nausea, vomiting, fever, diarrhea, or rashes. «No» recent travel or sick contacts. Good appetite. Good fluid intake and urinating. UTD with immunizations.

OGen - NAD. No clinical signs of cyanosis, dehydration, or lethargyVS - «»HEENT - oropharynx, nasopharynx, and tym mem «clear/cloudy/bulging/landmark loss/erythema/air-fluid level». No cervical lymphadenopathy notedCVS - S1, S2, RRR, no MRGRESP - CTAB with no nasal flaring, tracheal tug, intercostal indrawing, or accessory muscle use notedABD - normal appearance and BS, soft, NT, ND, no masses DERM - no skin changes

AEarache, query «»

PAdequate hydrationAvoidance of second-hand smoke and pacifier useOTC NSAID for comfortWatchful waiting if mild, > 6 months old, < 39 degrees Celsius, and < 48 hours «Ciprodex 4 drops to affected ear BID for 5 days»«Amoxicillin 80 mg/kg divided BID for 10 (< 2 years old) or 5 days (> 2 years old). Max 3 g»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents for query eating disorder the past «Duration». Patient notes fear of gaining weight with restriction of energy intake. Weight loss of «» with amenorrhea. Binge eating and purging reported. Denies SI/HI. «No» history of abuse or trauma. «No» family history of mental health disorders. «FIFERS».

OGen - NAD with «» eye contactVS - «»Appearance - «»Speech - «»Mood - «»Affect - «»HEENT - thyroid normal with no masses or cervical lymphadenopathyCVS - S1, S2, RRR, no MRGRESP - CTAB«GAD7 and PHQ9»

AEating disorder, query «»

PBlood work for extended lytes, creatinine, CBC, glucose, TSH, LFT, HCGECG BMDMeditation, breathing techniques, goal setting, and MoodgymCipralex titrated to 10 mg PO daily with side effects discussedVerbally contracted for safety; if the patient is experiencing SI/HI, they are to RTC, contact crisis (5199734435), or go to the ERRe-assess in «»

Time «»

SPatient presents for follow-up of eczema. Alleviated with «» and provoked with «». Diagnosed by «»

OGen - NADVS - «»DERM - Scaling erythematous patches with lichenification and excoriations seen on the «»

AEczema, «» controlled

PAvoid triggers such as detergents, hot water, sweating, and allergensApply moisturizer immediately after bathing«Emocort»«Betaderm»«Diprosone»«Dermovate»«Tacrolimus» to be applied to the affected area daily with maintenance following control of symptomsSide effects discussedRe-assess in «»

SPatients presents with epistaxis for «Duration». «Description of how epistaxis occurred». No previous bleeding episodes.

OGen - NAD. No jaundice or pallor notedVS - «»HEENT - «Description of epistaxis»

Procedure - «compression of nasal ala, local anesthetic, silver nitrate, and Bacitracin-covered gauze»

AEpistaxis, «» controlled

PPrevention with Vaseline«Urgent referral to ENT»RTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with erectile dysfunction for the past «Duration». Nocturnal erections present and able to achieve orgasm with ejaculation. «No» libido changes, relationship issues, BPH, or B-type symptoms reported.

OGen - NADVS - «»CVS - S1, S2, RRR, no MRGGEN - normal appearance

AErectile dysfunction, query «»

PLifestyle modifications including Mediterranean diet, decreased ETOH, weight loss, exercise, and smoking cessationBlood work for lytes, creatinine, LFT, CBC, HbA1c, total testosterone, lipid panel, TSH, LH, FSH, prolactin, and UAECGCardiac stress test (based on risk factor)«Sildenafil 25 mg PO to be used as directed»«Tadalafil 10 mg PO to be used as directed»Side effects discussedRe-assess if no improvement in «»

SPatient presents with fatigue for the past «Duration». Alleviated with «» and provoked with «». «VITAMIN CDE».

OGen - NAD. No jaundice or pallor VS - «»HEENT - nasopharynx, tym mem, and oropharynx are clear. Thyroid normalCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no massesEXT - gross motor strength and neurovascularly intactNEURO- CN2-12 intact with no cerebellar deficits. Gait normalDERM - no nail, hair, or skin changes

AFatigue, query «»

P«Blood work for extended lytes, creatinine, CBC, HbA1c, TSH, LFT, ESR, ferritin, and CK»«Infectious disease screening»«Imaging and studies»RTC or go to ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents for follow-up of fibromyalgia. Alleviated with «» and provoked with «». Diagnosed by «».

OGen - NADVS - «»MSK - various points of soft tissue TTP with no joint involvement

AFibromyalgia, «» controlled

P«Blood work for CBC, TSH, ESR, CRP, and CK»Exercises including yoga and water aerobicsAppropriate back and neck supportMeditation«Flexeril 10 mg PO TID PRN»«Naproxen 500 mg PO BID PRN»«Amitriptyline 10 mg PO qHS»«Pregabalin 50 mg PO qHS»«Duloxetine 60 mg PO daily»Side effects discussedRe-asses in «»

Time - «»

SPatient presents for follow-up of GERD. Alleviated with «» and provoked with «». «No» nausea, vomiting, weight loss, dysphagia, or CP. «No» melena or hematochezia. Diagnosed by «».

OGen - NAD. No jaundice or pallor VS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses

AGERD, «» controlled

PAvoidance of triggers such as coffee, smoking, chocolate, caffeine, ETOH, spicy foods, and NSAIDBlood work for CBC«Ranitidine 150 mg PO daily PRN»«Pantoprazole 40 mg PO daily PRN»«EGD if requirement of medications for 10 years»Side effects discussedRe-assess in 4 weeks and if not adequate, increase dosing and consider EGD

SPatient presents with «hematemesis/hematochezia/melena» for the past «Duration». Alleviated with «» and provoked with «». «No» nausea, vomiting, fever, abdominal pain, diarrhea, constipation, weight loss, or trauma. «No» recent travel or sick contacts.

OGen - NAD. No jaundice or pallor VS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no masses DRE - no fissures, hemorrhoids, or masses noted

AGI bleed, query «»

PBlood work for lytes, creatinine, LFT, CBC, PTT, INR «Hemoccult testing»«Imaging»«EGD and Colonoscopy»RTC or go to the ER if pain acutely worsensRe-assess if no improvement in «»

SPatient presents for follow-up of gout of «». Alleviated with «» and provoked with «». No other joints affected. Diagnosed by «».

OGen - NADVS - «»EXT - swollen and erythematous «» 1st MTP that is TTP with tophi present

AGout, «» controlled

PAvoidance of meat, shellfish, and ETOH«Blood work for uric acid»«X-ray of affected joint» «Naproxen 500 mg PO BID for 3 days»«If contraindicated, prednisone 1mg/kg PO daily for 5 days»«Pantoprazole 40 mg PO daily for 7 days»When stable, consider allopurinol 100 mg PO daily Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess in «»

SPatient presents with headache for the past «Duration». «No» previous episodes. «Location», «Character», alleviated with «», provoked with «», «Radiating», «Timing», «Severity». Headache does not awaken from sleep or worsen with Valsalva maneuver. «No» nausea, vomiting, fever, seizures, vision changes, photophobia, phonophobia, trauma, jaw pain, or neck pain. UTD with immunizations OGen - NAD. No jaundice or pallor VS - «»HEENT - NCAT. EOMI and PERRLA. Nasopharynx, tym mem, and oropharynx are clear. Fundoscopy normal. No temporal TTPNeck - negative jolt accentuation/Kernig/Brudzinski signCVS - S1, S2, RRR, no MRGRESP - CTABEXT - gross motor strength 5/5 with full ROM and sensation intactNEURO- CN2-12 intact with no cerebellar deficits. Gait normal

AHeadache, query «»

P«Blood work for lytes, CBC, ESR, CRP»«MRI of head»RTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents for follow-up of hypertension. Previously completed outpatient testing and average BP was «». «No» CP or dyspnea.

OGen - NAD. No pallor or jaundiceVS - «»HEENT - no JVDCVS - S1, S2, RRR, no MRGRESP - CTAB ABD - normal appearance and BS, soft, NT, ND, no bruits, no masses, no organomegaly EXT - no edema

AHypertension, «» controlled

PLifestyle modifications including Mediterranean diet, decreased ETOH, weight loss, exercise, and smoking cessationBP recording sheetBlood work for lytes, creatinine, CBC, HbA1c, and lipid panelUrinalysisECGManage contributing conditions«Medication based on chronic disease»Side effects discussedRTC or go to the ER if CP or dyspneaRe-assess in «»

SPatient presents for follow-up of hyperthyroidism. «No» insomnia, tremor, hair loss, weight loss, palpitations, amenorrhea, or diarrhea.

OGen - NAD. No central or peripheral cyanosis VS - «»HEENT - no lid lag or proptosis. Thyroid normal appearance with no TTP, masses, or bruitsCVS - S1, S2, RRR, no MRGEXT - no edemaDERM - no nail, hair, or skin changes

AHyperthyroidism, query «»

PBlood work for TSH, T4, T3, and thyrotropin receptor antibodies«Ultrasound of thyroid»«Radioactive uptake scan»«MRI of head»«Metoprolol 25 mg PO BID»Side effects discussedRe-assess in «»

SPatient presents for follow-up of hypothyroidism. «No» fatigue, weakness, hair loss, weight gain, depression, menorrhagia, or constipation.

OGen - NAD. No central or peripheral cyanosis VS - «»HEENT - no periorbital edema. Thyroid normal appearance with no TTP, masses, or bruitsCVS - S1, S2, RRR, no MRGEXT - no edemaDERM - no nail, hair, or skin changes

AHypothyroidism, query «»

PBlood work for TSH, T4, T3, and thyroid perioxidase antibodies«Ultrasound of thyroid»«Levothyroxine 50 mcg PO daily»Side effects discussedRe-assess in «»

SPatient presents for follow-up of IBS. Has experienced «» number of bowel movements daily. Alleviated with «» and provoked with «». «No» nausea, vomiting, fever, diarrhea, abdominal pain, weight loss, or trauma. «No» melena or hematochezia. «No» recent travel, sick contacts, or food outbreaks. Diagnosed by «».

OGen - NAD. No jaundice or pallor VS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no masses, no organomegaly

AIBS type «», «» controlled

PMeditationExercises including yoga and water aerobicsIncreased fiber intake and low FODMAP/lactose/gluten diet«Buscopan 10 mg PO TID PRN for pain»«PEG 3350 17 g in water PO daily for constipation»«Loperamide 2 mg PO TID for diarrhea»RTC or go to the ER if pain acutely worsensRe-assess in «»

SPatient presents with inability to conceive for the past «Duration». «Intercourse history». «Menstrual history». «Obstetrical history». LMP «». Last pap «». «No» dysmenorrhea, dyschezia, and dyspareunia. Currently taking PNV. UTD on immunizations.

OGen - NAD. No clinical signs of hyperandrogenismVS - «»CVS - S1, S2, RRR, no MRGRESP - CTABDERM - no hair, skin, or nail changes

AInfertility, query «»

PLifestyle modifications including Mediterranean diet, decreased ETOH, weight loss, exercise, and smoking cessationSemen analysisBlood work for HIV, Hep B/C, varicella, rubella, LH, FSH, estradiol, total testosterone, TSH, prolactin (day 3) and progesterone (day 21)Urine culture for gonorrhea and chlamydia Pelvic ultrasoundRe-assess in «»

SPatient presents with insomnia for the past «Duration». Difficulty «initating»«maintaining» sleep. Alleviated with «» and provoked with «». «No» morning headache, snoring, apnea, restless legs, or new stressors.

OGen - NAD. No jaundice or pallor VS - «»HEENT - EOMI and PERRLA. Nasopharynx, tym mem, and oropharynx are clearCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses, no organomegalyEXT - gross motor strength 5/5 with full ROM and sensation intactNEURO- CN2-12 intact with no cerebellar deficits. Gait normal. Dix-Hallpike maneuver negative

AInsomnia, query «»

PAvoid caffeine after lunch, ETOH within 6 hours of bedtime, and nicotine and fluids at bedtimeUnwind period prior to bed with reading and no electronic devicesOut of bedroom if not asleep within 15 minutesSleep consolidation > 5 hours «Blood work for extended lytes, creatinine, CBC, glucose, TSH»«Melatonin 5 mg PO qHS»«Tryptophan 2000 mg PO qHS»«Trazodone 25 mg PO qHS»«Zopiclone 3.75 mg PO qHS for 7 days»Side effects discussed«Sleep clinic referral»RTC or go to the ER if symptoms acutely worsenRe-assess in «»

SPatient presents with joint pain for the past «Duration». «Location», «Character», alleviated with «», provoked with «», «Radiating», «Timing», «Severity». «No» nausea, vomiting, fever, diarrhea, constipation weight loss, or trauma. «No» recent travel. No other joints affected.

OGen - NAD VS - «»Neck - full ROMShoulder - no swelling, erythema, atrophy, or deformity noted. Full active and passive ROM with no crepitus. Neg AC/Jobe/Posterior Cuff/Lift Off/Neer/Hawkin-Kennedy/Bicepital groove test. Neurovascularly intactKnee - no swelling, erythema, atrophy, or deformity noted. Full active and passive ROM with no crepitus. Neg Anterior drawer/Posterior Drawer/Varus Stress/Valgus Stress/Thessaly/Patellar TTP/Joint line TTP/fibular TTP. Neurovascularly intact and able to weight bearAnkle/Foot - no swelling, erythema, atrophy, or deformity noted. Full active and passive ROM with no crepitus. Neg Malleolar TTP/Navicular TTP/5th metatarsal TTP/MTP TTP/plantar fascia TTP. Neurovascularly intact and able to weight bearDERM - no nail, hair, or skin changes

AJoint pain, query «»

PRICEOTC NSAID«Blood work for CBC, INR, ESR, CRP, RF, LFT, urate, ANA, anti-ds DNA, anti-sm, C3, C4, UA»«Imaging» RTC or go to ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with a laceration that occurred «Duration». «Description of how laceration occurred».

OGen - NAD. No jaundice or pallor notedVS - «»EXT - «Description of function and neurovascularly intact»DERM - «»

Procedure - topical antiseptic and local anesthetic (xylo «» epi) used with irrigation performed. «» simple interrupted sutures were placed with Polysporin and «» bandage applied. The patient tolerated the procedure well with no complications noted

ALaceration, «» controlled

PSutures to be removed in «5/10/14» days«Tetanus prophylaxis»«Imaging»RTC or go to the ER if signs of infection or bleeding

SPatient presents with cessation of menstrual cycle for «Duration». Has noted «hot flashes», «vaginal dryness», «mood changes», «insomnia», and «urge»«stress» «incontinence». Last pap «» years ago. No contraindications to HRT.

OGen - NADVS - «»

AMenopause, «» controlled

P«Amenorrhea bloodwork if less than 45 years old»Exercise and daily calcium/vitamin D«HRT therapy (estrogen only if hysterectomy) or venlafaxine for vasomotor symptoms»«Vagifem 1 tab PV daily for 2 weeks then qweekly for vaginal atrophy»«Incontinence treatment based on type»Side effects discussedRe-assess in «»

SPatient presents for follow-up of migraines. Headache does not awaken from sleep or worsen with Valsalva maneuver. «No» nausea, vomiting, fever, seizures, vision changes, photophobia, phonophobia, trauma, jaw pain, or neck pain. Diagnosed on «». OGen - NAD. No jaundice or pallor VS - «»HEENT - NCAT. EOMI and PERRLA. Nasopharynx, tym mem, and oropharynx are clear. Fundoscopy normal. No temporal TTPCVS - S1, S2, RRR, no MRGRESP - CTABEXT - gross motor strength 5/5 with full ROM and sensation intactNEURO- CN2-12 intact with no cerebellar deficits. Gait normal

AMigraine, «» controlled

PAvoidance of triggers such as coffee, smoking, chocolate, caffeine, ETOH, and stressors«Naproxen 500 mg PO BID PRN»«Maxalt 10 mg PO q8hr PRN»«Amitripyline 10 mg PO qHS for prophylaxis»RTC or go to the ER if symptoms acutely worsenRe-assess in «»

SPatient presents for nail pain. Alleviated with «» and provoked with «».

OGen - NADVS - «»DERM - erythema noted along the lateral nail bed with discharge «»

Procedure - «»

AQuery «»

PAppropriate footwearSalt water soaking«Dental floss method»«Fucidin 2 percent to be applied to affected area TID for 7 days for mild paronychia»«Cephalexin 50 mg/kg PO QID for 7 days for severe paronychia»«Cephalxein 500 mg PO QID for 7 days severe paronychia»Side effects discussedRTC or go ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with neck pain for the past «Duration». «No» previous episodes. «Location», «Character», alleviated with «», provoked with «», «Radiating», «Timing», «Severity». «No» fever or trauma.

OGen - NAD. No jaundice or pallor VS - «»Neck - Full ROM with no TTPEXT - neurovascularly intact with +2 DTR b/l

ANeck pain, query «»

PContinue to stay active and return to work when ableAppropriate back and neck supportPhysiotherapy and massage therapy«LS X-ray greater than 4 weeks vs. MRI for radicular symptoms»«Acetaminophen 1000 mg PO QID PRN»«Naproxen 500 mg PO BID PRN»«Flexeril 10 mg PO TID PRN»«Amitriptyline 10 mg PO qHS»«Tramadol 50 mg PO daily to be titrated»Side effects discussedRTC or go to the ER if pain does not resolve or acutely worsensRe-assess if no improvement in «»

SPatient presents for follow-up of osteoarthritis. «Location», «Character», alleviated with «», provoked with «», «Radiating», «Timing», «Severity». «No» joint swelling. Diagnosed by «».

OGen - NADVS - «»«Joint» - «»

AOsteoarthritis, «» controlled

PExercises including yoga and water aerobicsX-ray of «»«Voltaren 1% gel to be applied BID PRN »«Acetaminophen 650 mg PO QID PRN»«Naproxen 500 mg PO BID PRN»Side effects discussedRe-assess in «»

SPatient presents for Pap. «Partners, Practices, Protection, Previous STI, Pregnancy». «Menstrual history». «Obstetrical history». LMP «». Last pap «»

OGen - NAD. No clinical signs of hyperandrogenismVS - «»GEN - external structures, vaginal wall, and cervix normal appearance. Cervical sample taken with cytobrush with «» in the room. No complications noted

AFemale Health Screen

PThe patient will receive her results within the next month. If not, she is to contact our officeRTC if any concerns

SPatient presents for follow-up of PUD. Alleviated with «» and provoked with «». «No» nausea, vomiting, weight loss, dysphagia, or CP. «No» melena or hematochezia. Diagnosed by «».

OGen - NAD. No jaundice or pallor VS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses

APUD, «» controlled

PAvoidance of triggers such as coffee, smoking, chocolate, caffeine, ETOH, spicy foods, and NSAIDBlood work for CBC and H. pylori «Ranitidine 150 mg PO daily PRN»«Pantoprazole 40 mg PO daily PRN»«Quadruple therapy pack for 14 days»Side effects discussedRe-assess in 4 weeks and if not adequate, increase dosing and consider EGD

SPatient presents with pharyngitis for the past «Duration». Alleviated with «» and provoked with «». «URTI symptoms.» «No» nausea, vomiting, fever, diarrhea, or rashes. «No» recent travel or sick contacts. Good appetite. Good fluid intake and urinating. UTD with immunizations.

OGen - NAD. No clinical signs of cyanosis, dehydration, or lethargyVS - «»HEENT - oropharynx, nasopharynx, and tym mem clear. No cervical lymphadenopathy notedCVS - S1, S2, RRR, no MRGRESP - CTAB ABD - normal appearance and BS, soft, NT, ND, no masses DERM - no skin changesMcIsaac score - «»Strep test - «»

APharyngitis, query «»

PAdequate hydration«Blood work for CBC, LFT, and monospot»«Avoid contact sports»«Throat culture»OTC NSAID for comfort«Amoxicillin 40 mg/kg/day for 10 days (max 3000 mg/day)»«Amoxicillin 500 mg TID for 10 days»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess in 48 hours if symptomatic or 2 weeks for culture

SPatient presents with positive pregnancy test. «Menstrual history». «Obstetrical history». LMP «». Last pap «». Currently taking PNV. UTD on immunizations.

OGen - NADVS - «»Pregnancy - «»

APregnancy

POb/Gyn referralBlood work for HIV, Hep B/C, VDRL, chlamydia, gonorrhea, varicella, rubella, HCG, CBC, ferritin, TSH, ABO/RH/antibodies, urinalysis and cultureDating ultrasoundFolic acid 0.4-4 mg/day based on riskCaffeine < 300 mg/dayFish < 2 servings/weekModerate intensity exercise with no risk factorsDiscontinue smoking/ETOH/substance use

SPatient presents for follow-up of psoriasis. Alleviated with «» and provoked with «». «No» joint involvement. Diagnosed by «»

OGen - NADVS - «»DERM - Scaling erythematous plaques with lichenification and excoriations seen on the «»

APsoriasis, «» controlled

PAvoid triggers such as smoking and ETOHApply moisturizer immediately after bathing«Emocort»«Betaderm»«Diprosone»«Dermovate»«Tacrolimus»«Dovonex»«Dovobet» to be applied to the affected area daily with maintenance following control of symptomsSide effects discussedRe-assess in «»

SPatient presents with a rash for the past «Duration». «Description and progression of rash». UTD with immunizations.

OGen - NAD. No clinical signs of cyanosis, dehydration, or lethargyVS - «»DERM - «»

ARash, query «»

P«Wound culture»«Betaderm 0.05 percent cream to be applied daily»«Clotrimazole 1 percent to be applied to affected area BID for 7 days»«Fucidin 2 percent to be applied to affected area TID for 7 days for mild Impetigo»«Cephalexin 50 mg/kg PO QID for 7 days for severe Impetigo and uncomplicated Cellulitis»«Cephalxein 500 mg PO QID for 7 days severe Impetigo and uncomplicated Cellulitis»«Cephalxein 500 mg PO QID and metronidazole 500 mg PO BID for 7 days for diabetic-related Cellulitis»«Septra DS 1 tab PO BID for 7 days for MRSA Abscess»«Septra DS 1 tab PO BID and metronidazole 500 mg PO BID for 7 days for diabetic-related Abscess»«Valacyclovir 1000 mg PO TID for 7 days for Herpes Zoster»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with a red «» eye for the past «Duration». «No» discharge, changes in visual acuity, pain, photophobia, pruritis, or trauma with sensation of foreign body. «No» use of contacts

OGen - NADVS - «»Snellen - «»HEENT - conjunctival injection of «» eye with «no» discharge. EOMI and PERRLA. No FB with eyelid inversion. Fundoscopy normal with cup:disc ratio < 0.5. Fluoroscein stain normal. Oropharynx, nasopharynx, and tym mem clear. No cervical lymphadenopathy.DERM - no nail, hair, or skin changes

ARed eye, query «»

P«Orbital X-ray»«Warm compresses and frequent hand washing»«OTC lubricating drops»«Fucithalmic 1 % ophthalmic drops drop per eye BID for for 7 days»«Ciprofloxacin 0.3 % ophthalmic drops 1 drop per eye QID for 7 days for contact lens wearer»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with a sinus pressure for the past «Duration». «Congestion», «obstruction», «purulent nasal discharge», and «anosmia». «Non»productive cough. Alleviated with «» and provoked with «». «No» nausea, vomiting, fever, diarrhea, or rashes. «No» recent travel or sick contacts. UTD with immunizations.

OGen - NAD. No jaundice or pallor VS - «»HEENT - oropharynx, nasopharynx, and tym mem clear. Sinus TTP with no periorbital swelling. No cervical lymphadenopathyCVS - S1, S2, RRR, no MRGRESP - CTAB

ARhinosinusitis, query «»

PNasal irrigation, steam inhalation, and warm compresses«Avamys 27.5 mcg 2 sprays per nostril daily for mild symptoms and adults»«Amoxicillin 80 mg/kg/day for 10 days (max 3000 mg/day for children)»«Amoxicillin 500 mg TID for 10 days if no improvement in 3 days or severe symptoms in adults»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents for follow-up of rosacea. Alleviated with «» and provoked with «». Diagnosed by «»

OGen - NADVS - «»DERM - erythema with papules and pustules seen distributed on the central face

ARosacea, «» controlled

PAvoid triggers such as smoking and ETOHApply moisturizer immediately after bathing«Metronidazole gel/cream/lotion to be applied BID»«Minocycline 100 mg daily for 90 days»Side effects discussedRe-assess in «»

SPatient presents with concerning skin lesion that has been present for «Duration». The patient has has a history of excess UV exposure with a «» skin tone. «No» fever, night sweats, or weight loss reported. «No» family history or previous skin cancers.

OGen - NAD. No jaundice or pallor notedVS - «»DERM - «» with no supraclavicular or axillary lymphadenopathy

Procedure note - «»

ASkin lesion, query «»

P«Cryotherapy vs ingenol mebutate»«Excisional biopsy to be sent for pathology»Re-assess in «»

SPatient is here to discuss smoking cessation. «Relevance, risks, rewards, roadblocks, repetition».

OGen - NAD. No jaundice or pallor VS - «»

ASmoking cessation

PSet quit dateTell othersAnticipate challengesRemove paraphernaliaNicotine patch/gum/inhalerChampix/Zyban starter packRe-assess in «»

SPatient presents with query STI for the past «Duration». «Partners, Practices, Protection, Previous STI, Pregnancy». «No» nausea, vomiting, fever, abdominal pain, discharge, or dysuria. «LMP». Last pap «».

OGen - NAD. No jaundice or pallor VS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no masses, no organomegalyBACK - no CVA TTPGEN - normal appearance with no swelling, erythema, or discharge. «No» cervical motion TTP. No inguinal lymphadenopathy«Urinalysis and Pregnancy Test»

AQuery «»

PSafe sex practices including barrier protection, avoidance of ETOH/drugs, and contraceptionBlood work for CBC, Hep B/C, VDRL, HIV, and HSV-2Oral, rectal,urine, and vaginal culture including gonorrhea, chlamydia, and trichomonasNotification of public health«Ceftrixaxone 250 mg IM and doxycycline 100 mg PO BID x 10 days if epididymitis»«Ceftriazone 250 mg IM and azithromycin 1000 mg PO one time if urethritis/cervicitis»«Cefixime 800 mg PO and doxycycline 100 mg PO BID x 10 days if PID»«Patient-applied Imiquimod 5 percent to be applied three times nightly and washed off in the morning if HPV»«Physician-applied Trichloroacetic acid/podophyllotoxin application weekly if non/pregnant HPV»«Valacyclovir 1000 mg BID x 7 days if primary HSV»«Valacyclovir 1000 mg daily x 3 days if recurrent HSV»Abstain from intercourse 7 days post-treatment with test of cure in 1 monthRTC or go to the ER if pain acutely worsensRe-assess if no improvement in «»

SPatient is here for post-strep culture following treatment. Symptoms have resolved with no other issues noted.

OGen - NADHEENT - oropharynx clear

AStrep, treated

PThroat cultureRTC if any concerns

SPatient presents with syncope that occurred «Time and Date». «Description of events preceding episode». «No» previous episodes. «No» headache, nausea, vomiting, fever, amnesia, seizure, weakness, tongue biting, CP, palpitations, dyspnea, palpitations, or incontinence.

OGen - NAD. No jaundice or pallor VS - «Seated and standing BP»GCS - «»HEENT - NCAT. EOMI and PERRLA. Nasopharynx, tym mem, and oropharynx are clear. No carotid bruitNeck - full ROM with no midline TTPCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses, no organomegalyEXT - gross motor strength 5/5 with full ROM and sensation intactNEURO - CN2-12 intact with no cerebellar deficits. No tremor and gait normal

ASyncope, query «»

PMaintain hydrationAvoid prolonged standing and slow positional changesSupine if symptomatic«Blood work for extended lytes, creatinine, CBC, glucose, TSH»«ECG»«Holter monitor»«Echocardiogram»«EEG»«MRI of head»Side effects discussedRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

0.1 mL administered intradermally at the inner left forearmInduration noted to be «» mm at site of injectionFollow-up in 48-72 hours for reading and 1 week for second step of testing

SPatient presents for follow-up of tension headache. Headache does not awaken from sleep or worsen with Valsalva maneuver. «No» nausea, vomiting, fever, seizures, vision changes, photophobia, phonophobia, trauma, jaw pain, or neck pain. Diagnosed on «». OGen - NAD. No jaundice or pallor VS - «»HEENT - NCAT. EOMI and PERRLA. Nasopharynx, tym mem, and oropharynx are clear. Fundoscopy normal. No temporal TTPCVS - S1, S2, RRR, no MRGRESP - CTABEXT - gross motor strength 5/5 with full ROM and sensation intactNEURO- CN2-12 intact with no cerebellar deficits. Gait normal

ATension headache, «» controlled

PAvoidance of triggers such as coffee, smoking, chocolate, caffeine, ETOH, and stressors«Naproxen 500 mg PO BID PRN»«Amitripyline 10 mg PO qHS for prophylaxis»RTC or go to the ER if symptoms acutely worsenRe-assess in «»

SPatient presents for query thromboembolism for «Duration». «No» CP, dyspnea, immobilization, or recent injury. No active cancer.or previous PE/DVT.

OGen - NAD. No central or peripheral cyanosisVS - «»HEENT - No JVDCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance, soft, NT, ND, no bruits, no masses, no organomegaly. EXT - no swelling, edema, erythema. Neg Homan sign Well's score for DVT/PE - «»

AQuery «»

PAdequate hydration, loose clothing, early ambulation, compression stockings«D-dimer (low risk DVT or negative venous doppler)»«Venous doppler (mod/high risk DVT)»«Rivaroxiban 15 mg BID for 21 days then 20 mg PO daily»Side effects discussedRTC or go to the ER is symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with tremor for the past «Duration». Alleviated with «» and provoked with «». «Areas involved». «No» headache, nausea, vomiting, fever, seizures, or LOC.

OGen - NAD. No jaundice or pallor VS - «»HEENT - EOMI and PERRLA. Nasopharynx, tym mem, and oropharynx are clearCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses, no organomegalyEXT - gross motor strength 5/5 with full ROM and sensation intact with no rigidity with with +2 DTR b/lNEURO - CN2-12 intact with no cerebellar deficits. No tremor and gait normal

ATremor, query «»

P«Blood work for extended lytes, creatinine, CBC, LFT, glucose, TSH»«MRI of head»RTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents with vaginal discomfort for the past «Duration». Alleviated with «» and provoked with «». «Description of discharge and odor». «No» nausea, vomiting, fever, abdominal pain, incontinence, or flank pain. «No» recent new sexual partners. LMP «». Last pap «».

OGen - NAD. No jaundice or pallor VS - «»CVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance, soft, NT, ND, no masses BACK - no CVA TTPGEN - normal appearance with no swelling, erythema, or discharge. «No» cervical motion TTP. No inguinal lymphadenopathy«Urinalysis and Pregnancy Test»

AVaginitis, query «»

P«Blood work for extended lytes, creatinine, CBC»«Urine and vaginal culture including gonorrhea, chlamydia, and trichomonas»«Metronidazole 2000 mg PO one time for bacterial vaginosis and Trichomonas (partner treatment)»«Fluconazole 150 mg PO one time for Candidiasis»«Vagifem 1 tab PV daily for 2 weeks then q3 days for vaginal atrophy»Side effects discussedAbstain from intercourse 7 days post-treatment with test of cure in 1 monthRTC or go to the ER if symptoms acutely worsenRe-assess if no improvement in «»

SPatient presents for query a wart on «». Previous treatment includes «».

OGen - NADVS - «»DERM - «»

Procedure - a 15 blade was used for paring the affected area with the subsequent application of cantharidin with tape coverage

AVerruca «»

PWill resolve spontaneously in immunocompetent patientsOTC salicyclic acid after soaking area in warm water and paring prior to application with tape coverage, repeating every 48 hoursRe-assess in 3 weeks for re-application

SPatient presents with weight loss of «» over the past «Duration». «VITAMIN CDE».

OGen - NAD. No jaundice or pallor VS - «»HEENT - nasopharynx, tym mem, and oropharynx are clear. Thyroid normalCVS - S1, S2, RRR, no MRGRESP - CTABABD - normal appearance and BS, soft, NT, ND, no bruits, no masses, no organomegalyEXT - gross motor strength and neurovascularly intactNEURO- CN2-12 intact with no cerebellar deficits. Gait normalDERM - no nail, hair, or skin changes

AWeight loss, query «»

P«»RTC or go to ER if symptoms acutely worsenRe-assess in «»

SPatient presents for follow-up of osteoporosis. «No» previous fragility fracture. Diagnosed by «».

O

Gen - NADVS - «»

AOsteoporosis, «» controlled

PWeight-bearing and resistance exercises with falls preventionBlood work for extended lytes, creatinine, CBC, TSH, ALP, and SPEP«Calcium 1200 mg and vitamin D 2000 IU daily»«Alendronate 70 mg PO weekly»«Denosumab 50 mg SC q6months»Side effects discussedRe-assess in «»