Abd pain

Patient came in with complain of epigastric pain for few months.

According to the patient , he is having epigastric discomfort and pain usually after eating.
Also complain of gas and belching . Patient denies any pain in right upper quadrant.
Denies nausea/vomiting.
Denies any diarrhea.
No fever/ chills
Ros:
GENERAL: no fever, chills, weakness or lethargy.
EYE: no diplopia, blurred vision or photophobia.
ENT: No Ear ache, Sore throat, and nasal discharge.
Neck: No Swelling, no lymphadenopathy.
RESPIRATION: no cough, no sob or wheezing.
CVS: no chest pain, dizziness or palpitation.
GI: see hpi
Urinary: No dysuriaa, hematuria, frequency and urgency.
Musculoskeletal: No muscles or joint pain.
Skin: No rash.

Objective
Edit
General: normotensive, in no apparent distress.
Head: normocephalic, no evidence injury, no tenderness. Ears: EACs clear, TMs clear bilaterally. Eyes: no scleral
icterus, conjunctivae clear, PERRLA, fundi grossly normal. Neck: supple, no lymphadenopathy. Chest: clear to
percussion and auscultation.
Heart: regular rhythm, no gallops or murmurs.
Abdomen: mild epigastric tenderness, bowel sounds normal.

Assessment
Record
No assessment recorded.
Diagnoses attached to this encounter:

(041.86) H. pylori gastritis

Plan
Edit Print Visit Summary
Serum H.pylori done in the clinic which was positive.
Will treat patient with amoxicillin , clarithromycin and omeprazole.
Ask patient to H.pylori stool antigen test in 3 months.
RTC as needed.

Refill prescription

Subjective Edit
Patient came in for prescription refill.
Patient is in one of our study for DM.
Patient labs done in study.
Patuient kidney functional normal.
Patient GFR about <20.
Referred patient multiple time to nephrologist, as patient does not have any medical
insurance and resources so patient is not following any nephrologist and not going
for the dialysis.
Explained all these things and discussed with the daughter.
Patient need refill of DM and blood pressure medication.

ROS:.
GENERAL: no fever, chills, weakness or lethargy.
Neck: No Swelling, no lymphadenopathy.
RESPIRATION: no cough, no sob or wheezing.
CVS: see hpi.
GI: No abdominal pain, nausea, vomiting and constipation.
endo: see HPI
Objective Edit
Physical exam:.
General: Hypertensive, no acute distress.
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs show no rales, no wheezes, no rhonchi.
Heart: RR, no murmurs, no rubs, no gallops.

Abdomen: Soft, no tenderness, no masses, BS normal.

lower extremity: trace edema
Assessment Record
No assessment recorded.
Diagnoses attached to this encounter:

(250.00) Diabetes mellitus

(401.9) Essential hypertension
(586) Renal failure, unspecified
Plan Edit Print Visit Summary
Refill of medication given.
Ask to follow up with nephrologist if possible.
Explain patient situation and explain in detail patient's life threatening low GFR.
Patient sound understood but as they don't have option , there is not much we can
do.
Ask patient to go ER if condition get worse.

CHild Fever
Subjective Edit
Patient brought by the father with complain of fever.
Patient is playful as usual.
Patient is not eating and drinking well.
Patient is developing fever of 100 and 101.
For last 2 days patient's other sibilings was positive for strep.

ROS:
GENERAL: Low Grade fever, chills, weakness or lethargy.

EYE: no diplopia, blurred vision or photophobia.

ENT: See Hpi.
Neck: No Swelling, no lymphadenopathy.
RESPIRATION: no cough, no sob or wheezing.
CVS: no chest pain, dizziness or palpitation
GI: No abdominal pain, nausea, vomiting and constipation.

Objective Edit
Physical examination:..
General: Normotensive, in no acute distress..
Ears: EAC's clear, TM's normal..
Nose: Mucosa normal, no obstruction.
Pharynx erythematous, swollen, with exudates and petichiae..
No sinus tenderness.
Neck: Supple, no masses, no thyromegaly, no bruits..
Chest: Lungs clear, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Soft, no tenderness, no masses, BS normal.

Assessment Record
No assessment recorded.
Plan Edit Print Visit Summary
Patient Rapid Strep Test is positive.
Drink plenty of water..
Tylenol or Advil as needed for pain or fever..

Steam inhalation with vicks TID..

OTC decongestants of choice, prn..
Medication as below:..
Return to clinic in 3-4 days if not better..
Go to ER if condition get worse..

Generic
Ros:
GENERAL: no fever, chills, weakness or lethargy.
EYE: no diplopia, blurred vision or photophobia.
ENT: No Ear ache, Sore throat, and nasal discharge.
Neck: see hpi.
RESPIRATION: no cough, no sob or wheezing.
CVS: no chest pain, dizziness or palpitation.
Abdomen: soft non tender abdomen , normal bowel sound.
Skin: No rash.
Physical Exam:

General: Normotensive, in no acute distress.

Eyes: PERRLA, EOM's full, conjunctivae clear, fundi grossly normal.
Ears: EAC's clear, TM's normal.
Nose: Mucosa normal, no obstruction.
Throat: Clear, no exudates, no lesions.

Chest: Lungs clear, no rales, no rhonchi, no wheezes.

Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Soft, no tenderness, no masses, BS normal.
Skin: Normal, no rashes, no lesions noted.

COUGH
Patient denies any fever/chill.
No Runny Nose.
No Earache.
Subjective Edit

Patient came in with complain of cough for 5 days.

Patient denies fever , but having chill.
Cough is productive , producing whitish yellow sputum.
Patient denies any sick contact.
Patient complaining to stuffy nose and ear plugged in sensation.
Patient complaining to facial pain.
Patient tried amoxicillin 500mg twice a day for last 2 days , but patient condition
instead of getting better it's getting worse.

ROS:
GENERAL: no fever, chills, weakness or lethargy.
EYE: no diplopia, blurred vision or photophobia.
ENT: See HPI

Neck: No Swelling, no lymphadenopathy.

RESPIRATION: See HPI
CVS: No chest pain, dizziness or palpitation.
GI: No abdominal pain, nausea, vomiting and constipation.
Genitourinary: No Dysurea, burning
Musculoskeletal: No muscles or joint pain.
Endo:NO diabetes, hypo or hyperthyroidism.

Objective Edit
Physical Examination:.
Gen: Afebrile but appears acutely ill..
Ears: TM's normal bilaterally..
Nose: nasal mucosa edematous, clear rhinorrhea, moderate airway obstruction..
Sinus tenderness to percussion..
Pharynx mildly erythematous, no exudates..
Neck: Supple, no lymphadenopathy..
Lungs: mildly rhonchitic, no wheezes, no rales..
CVS: NSR, No murmur, rubs, gallops.
Abdomen: soft, non tender, no mass, BS present.
Assessment Record
No assessment recorded.
Plan Edit Print Visit Summary
Increase fluids, rest..
OTC analgesic, Tylenol, ibuprofen prn..
OTC decongestants of choice, prn..
Salt water gargles, ice chips to soothe throat tid..

Steam expectoration is recommended..

Medications as detailed below:..
RTC prn not improved 3-5d, sooner if worsens..
Go to ER if condition get worse.

DM follow up
Patient came in for follow up of DM2.
Patient is not taking medicine for 2 weeks period.
Patient is not excercising regularly.
Patient is following ADA diet.
Patient has no complain at this point.

Ros:.
GENERAL: no fever, chills, weakness or lethargy.
EYE: no diplopia, blurred vision or photophobia.
ENT: No Ear ache, Sore throat, and nasal discharge.
Neck: No Swelling, no lymphadenopathy.
RESPIRATION: no cough, no sob or wheezing.
CVS: no chest pain, dizziness or palpitation.
GI: No abdominal pain, nausea, vomiting and constipation.
Urinary: No dysurea, hematuria, frequency and urgency.
Genital: No vaginal or urethral discharge and no lesions.
Endo: see hpi
Physical Examination:
General: Normotensive, in no acute distress.
General: BP normal, no acute distress.
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs show no rales, no wheezes, no rhonchi.
Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Soft, no tenderness, no masses, BS normal.
Extremities: Normal ROM, no deformities, no edema, no erythema.

Follow ADA diet.

Take medication regularly.
Medication as below.
Side effect of medication explained.
Ask patient to go for diabetic eye exam

RTC is one month for follow up.

Go to ER if condition get worse.
NEWW TEMPLATE:

Subjective
Edit
Patient came in with complain of voice loss for 1 week.
According to the patient it started suddenly , initially it was getting better but progressively it got worse.
Patient had mild sore throat.
Denies runny nose or ear ache.
No sick contacts.
Patient also complaining of white patches inside the cheeks.
Denies any tobbaco chewing or smoking.
ROS:
GENERAL: Low Grade fever, chills, weakness or lethargy. EYE: no diplopia, blurred vision or photophobia. ENT:
See Hpi. Neck: No Swelling, no lymphadenopathy. RESPIRATION: no cough, no sob or wheezing. CVS: no chest
pain, dizziness or palpitation
GI: No abdominal pain, nausea, vomiting and constipation. Genitourinary: No Dysurea, burning Musculoskeletal:
No muscles or joint pain. Endo:NO diabetes, hypo or hyperthyroidism. NEURO: No seizures, no headache, no focal
neurologic deficit.

Objective
Edit
Physical examination:..
General: Normotensive, in no acute distress..
Head: Normocephalic, no lesions..
Ears: EAC's clear, TM's normal..
Nose: Mucosa normal, no obstruction.
Pharynx mildly erythematous, no exudates..
No sinus tenderness.
Neck: Supple, no masses, no thyromegaly, no bruits..
Chest: Lungs clear, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Soft, no tenderness, no masses, BS normal.

ROS:

GENERAL: no fever, chills, weakness or lethargy.

EYE: no diplopia, blurred vision or photophobia.
ENT: No Ear ache, Sore throat, and nasal discharge.
Neck: No Swelling, no lymphadenopathy.
RESPIRATION: No cough, no sob or wheezing.
CVS: No chest pain, dizziness or palpitation.
GI: No abdominal pain, nausea, vomiting and constipation.
Genitourinary: No Dysuria, no hematuria.
Musculoskeletal: No muscles or joint pain.
Skin : No rash
Neuro : See hpi
General: Normotensive, in no acute distress.
Head: normocephalic, no evidence injury, no tenderness.
Ears: EACs clear, TMs clear bilaterally.
Eyes: no scleral icterus, conjunctivae clear, PERRLA, fundi grossly normal
Nose : Normal mucosa , no obstruction
Pharynx : Normal , no pnd
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs show no rales, no wheezes, no rhonchi.
Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Soft, no tenderness, no masses, BS normal.
Extremities: Normal ROM, no deformities, no edema, no erythema.

Physical Exam:
General: Normotensive, in no acute distress.
Eyes: PERRLA, EOM's full, conjunctivae clear, fundi grossly normal.
Ears: EAC's clear, TM's normal.
Nose: Mucosa normal, no obstruction.
Throat: Clear, no exudates, no lesions.
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs clear, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.

Abdomen: Soft, no tenderness, no masses, BS normal.

GU: Normal, no lesions, no discharge, no hernias noted.
Pelvic: BUS normal, no discharge, cervix normal, uterus and adnexae normal.
Rectal: No lesions, no hemorrhoids, stool heme negative.
Back: Normal curvature, no tenderness.
Extremities: FROM, no deformities, no edema, no erythema.
Neuro: Physiological, no localizing findings.
Skin: Normal, no rashes, no lesions noted.