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All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Do not merely copy and paste a prewritten note element into a patient's chart - "cloning" is unethical, unsafe, and potentially fradulent.
_ year old F presents for well woman exam. She has no concerns at this time.
Sexual Sexually active with 0 male spouse. No new sexual partners since last exam.
History of STI: None
Has been tested for HIV, HCV, syphilis. _
Contraception method:
Cervical
Last pap:
History of abnormal pap: None
Has received a full course of the HPV vaccine.
Breast
Last mammogram: Does self breast exams monthly. _
Menstruation
-Menarche at age:
-Periods every
-Duration of periods:
-Significant symptoms:
-Menopause at age
Obstetric history
-G _ P_ A_
-Delivery history:
-Obstetric history
-G1: Delivery method - _, PNC _, Delivery complications _
-G2: Delivery method - _, PNC _, Delivery complications _
Other medical history
Family history
Breast cancer: None
Ovarian cancer: None
Uterine cancer: None
Other significant FH:
Social history
Tobacco use: Never
Alcohol use: Never
Drug use: Never
Exercises _ times per week
Lives with
Occupation:
Intimate partner violence/abuse:
Health Maintenance: -
Colonoscopy _ (due for repeat _)
- A1c _ % (Date: _)
- ASCVD _% (lipid screening every 5 years if low risk, q3 years if increased risk)
-Total cholesterol: _ -HDL: _ -LDL: _
- AAA screen: _ (age 65-75 w/ smoking history)
- Lung cancer screening CT: _ (55-80 w/ at least 30 packyear smoking hx)
Immunizations:
- Td booster _ (due for repeat dose _) [every 10 years]
- Zoster (Shingrix)_ [Age 50, dose @ 0 and 2-6 months]
- PPSV23 (Pneumovax) _ [1 dose @ 65 or 5 years after previous dose if given <65. Give 19-64 if chronic heart/liver/lung dz, alcoholism, smoking, immunocompromised, asplenia, CSF leak, or cochlear implant]
- PCV13 (Prevnar) _ [Age 65 based on shared decision-making. If given, wait at least 1 year before giving PPSV23]
- Influenza _
- COVID _ Prior documentation reviewed. Medications reconciled.
[Age] year old [Gender] who presents to clinic for a wellness exam. Patient has no concerns at this time.â–Ľ
Medical History: [Problems]
Medications: [* Medication List]
OTC Supplements:
Allergies: [Allergies]
Surgeries: [* Procedures]
Recent ED Visits and Hospitalizations: Noneâ–Ľ
Social History:
- Lives withâ–Ľ
- Occupation: _â–Ľ
- Tobacco use: _â–Ľ
- Alcohol use: _â–Ľ
- Recreational Drug use: deniesâ–Ľ
- Diet: _â–Ľ
- Exercise: times/weekâ–Ľ_â–Ľ
- Sexual health _â–Ľ. _â–Ľ
Family History:
- Father - _â–Ľ
- Mother - _â–Ľ
- Siblings - _â–Ľ
- Other: _â–Ľ
Health Maintenance:
- Last Colonoscopy _â–Ľ (due for repeat _â–Ľ)
- Last A1c _â–Ľ(_â–Ľ)
- Lipid panel: total cholesterol _â–Ľ, HDL _â–Ľ, LDL _â–Ľ(lipid screening every 5 years if low risk, q3 years if increased risk)
- AAA screen: _â–Ľ(age 65-75 w/ smoking history)
- Lung cancer screening CT: _â–Ľ (55-80 w/ at least 30 packyear smoking hx)
- Pap _â–Ľ
- Mammo _â–Ľ
- DEXA _â–Ľ
- HIV _â–Ľ
- HCV _â–Ľ
– Syphilis _▼
- PSA _ (Age 55-69 and with clear preference for screening)
Immunizations:
- Td booster _â–Ľ(due for repeat dose _â–Ľ) _â–Ľ
- Zoster (Shingrix): _â–Ľ_â–Ľ
- PPSV23 (Pneumovax) _â–Ľ_â–Ľ
- PCV13 (Prevnar) _â–Ľ_â–Ľ
- Influenza Receivedâ–Ľ
- COVID fully vaccinated with boosterâ–Ľ_â–Ľ
Prior documentation reviewed.
2021 Guidelines
Lipids (40-75 y/o) -
10-yr CVD Risk Assessment - Estimator used -
Diabetes Screening (40-70 y/o)-
Aspirin Prophylaxis (50-59 y/o w/ 10+% ASCVD) -
HIV Screen (15-65 y/o) -
Hep C Screening (18-79 y/o): Date:
Lung Cancer Screening (50-80 y/o 20+ pack year smokers, quit <15 years) -
Colorectal Cancer Screening Date (45-75 y/o, 76-85 (shared decision making)):
Annual: [ ] gFOB or FIT (+/- flex sig q 10y)
Every 3 years: [ ] FIT-DNA
Every 5 years: [ ] Flex Sig [ ] CT Colonography
Every 10 years: [ ] Colonoscopy
Tetanus (Td/Tdap) q10y -
Influenza Vaccine -
Zoster Vaccine (50+ y/o) -
Pneumococcal Vaccine - PPSV23 (65+): PCV13 (shared decision making):
HPV Vaccine (up to 26 for all, 27-45 shared decision making) -
Women:
Cervical Cancer Screen - Pap (21-65 y/o): HPV:
Breast Cancer Screening -
Mammogram (50-74 biannually, 40-50 y/o shared decision making) -
BRCA Risk Assessment (family hx) -
Breast cancer risk reducing medications (35+ y/o, NCI Breast cancer risk assessment)
GC/Chlamydia Screen (<24 y/o sexually active) -
Osteoporosis Screen (65+ y/o, younger with FRAX >8.4%) -
Folic Acid -
Men:
Aortic Aneurysm Screen (65-75 y/o if ever a smoker) -
General: alert, no acute distress.
Respiratory: Lungs CTA, respirations normal work of breathing
Cardiovascular: regular rate and rhythm, murmur absent
Abdomen: abdomen soft non tender, bowel sounds present
Neurological: oriented, LOC appropriate for age, moves all extremities
Comprehensive physical exam. Make sure only to include what you did and delete the rest.
Gen: WD, WN, lying comfortably in NAD.
Head: Normocephalic, atraumatic.
Eyes: PERRLA, EOMI, non-injected, anicteric.
Ears: EAC clear. TM without erythema and non-bulging.
Mouth: MMM, normal dentition, oropharynx without erythema or exudates.
Neck: Supple, NTTP, no thyromegaly. No cervical, submandibular or supraclavicular LAD.
Chest: NTTP, no crepitus.
Cardio: RRR, no m/g/r.
Lungs: CTAB, no w/r/r, no increased WOB.
Abd: Soft, ND, NTTP, NABS, no HSM.
MSK: FROM, NTTP, no synovitis, no edema.
Ext: Symmetric 2+ pulses, cap refill < 2s.
Neuro: A&Ox3. CNII-XII without deficits. Sensation intact and equal bilateral. Strength 5/5 throughout. Neg cerebellar signs.
Psych: Appropriate affect, insight, judgment and memory.
Vaginal: normal vulva and perineum, normal vagina, normal cervix without mass/lesion/tenderness. Some white thin discharge, no bleed, pooling.
GU: Scrotum normal appearance, no ulcerations/lesions/erythema. No scrotal swelling. No palpable masses BL. Testicular cords nonedematous. Testicle non TTP. Cremasteric reflex intact BL. No urethral discharge. No palpable herniation with cough.
Baby [Gender] is a former [Est Gestational Age at Birth] week infant who is now [Age] old with hyperbilirubinemia. Baby has otherwise been well, voiding and stooling appropriately. Breastfeeding every 2-3 hours. Infant is DAT - and remainder of mom's labs during pregnancy were seroprotective. Hyperbilirubinemia risk factors include- prematurity (<38 weeks), ABO incompatibility, exclusive breastfeeding, prior sibling on phototherapy, cephalohematoma, and East Asian Race. Neurotoxicity risk factors include- isoimmune hemolytic disease, G6PD deficiency, asphyxia, lethargy, temperature instability, sepsis, acidosis, albumin <3.0g/dL
Today's weight: _ (down _ from bw)
Birth weight: [Birth Weight]
Today's bilirubin: _ ( threshold _ for a _risk infant at _ hours of life)
Discharge bilirubin: _ (_hours of life)
Hyperbilirubinemia:
Plan for admission to inpatient pediatric service for phototherapy and monitoring of serum bilirubin level. At this time, suspect breastfeeding jaundice as an etiology for the patient's condition given _poor latch, decreased weight, decreased maternal milk supply. Less likely causes include inherited red blood cell membrane defect, erythrocyte enzymatic defect, and Crigler-Najjar UGT deficiency. We will not pursue further work-up at this time unless infant's condition does not respond to treatment as expected.
-Admit for triple phototherapy (okay to just use bili-blanket when feeding)
-Bilirubin level tomorrow am, no need for immediate re-check
-Lactation consult
-Breastfeed q2-4 hours and supplement with 30mL formula after breastfeeding
-I&O's
-daily weights
-Repeat bili, CBC with manual differential, and reticulocyte count if bilirubin doesn’t respond to phototherapy as expected
Dispo: Likely discharge tomorrow if baby continues to have appropriate oral intake, adequate weight gain, and the bilirubin level decreases to below threshold for phototherapy.
---------------------------------------------------------------------------------------------------------------------------------------------
_Term infant with hyperbilirubinemia from high indirect bilirubin. _ evidence of hemolytic disease; Moms blood type is _. Baby's cord blood was _ and maternal labs were _seroprotective. Well appearing on exam and vitals appropriate. Breast_Formula feeding fairly well; down _ from birth weight and stooling regularly. _Still within period for physiologic jaundice and due to breast feeding at higher risk for breast feeding jaundice. _Other causes of indirect hyperbilirubinemia would include Hereditary Spherocytosisk, G6PD, ABO incompatibility, and breast milk jaundice but lower concern at this point given _ normal CBC and retic and age of patient. Patients bilirubin level is above phototherapy threshold to treat; plan admit patient to 4N and start phototherapy and monitor Bilirubin levels.
FEN/GI:
-Continue breastfeeding Ad Lib on demand.
-Encouraged Mom to use breast pump to keep up supply.
- _ Consider supplementing with Formula if needed.
HEME:
-Start phototherapy with standard protocol.
-Keep infant under lights as much as possible, but can remove from lights to breast feed.
-Repeat bilirubin level tomorrow morning.
Disp: Possible discharge tomorrow if bilirubin level acceptable.
ALPE dotphrase made in 2021. ALPE is a new diagnosis still getting new research so this can be outdated.
#ALPE (Acute renal failure with severe loin pain after anaerobic exercise)
_ day hx of LBP and decreased UOP, elevated Cr (_), CK (_) not suggestive of Rhabdo after rigorous exercise, though CK may still peak 24-72 hours from inciting injury
UA+ _ WBC/RBC, _ protein, no bacteria, no casts
Cr _ on admit (BUN _, K _)
Non-contrast CT: (perinephric stranding common, contrast study would show wedge shaped infarcts)
Low suspicion for pyelonephritis given no fever/chills, no bacteruria, and only mild flank pain.
-Admit to MSW
-VS q4
-BMP, Mg, Phos, UA, urine electrolyte, CK 6 hrs from admit, then qAM BMPs and CK
-LR _ mL/hr for at least 24 hr, pending cr improvement/return of normal urinary function.
Rec urgent transfer to NMCSD for dialysis IF meets following criteria:
--- severe hyperkalemia (>6 mEq or rapidly rising)
--- severe acidosis (pH <7.1-7.2)
--- refractory volume overload evidenced by increasing O2 demand (may trial diuretics if approaching this)
--- uremic complications (pericarditis, any unexplained AMS or may be considered if BUN >110-140)
#AKI
Elevated creatinine and oliguria as above in setting of likely ALPE vs rhabdo
-Avoid nephrotoxic drugs
-labs as above
#Proteinuria
Likely 2/2 dehydration after intense exercise
UA _ protein, no casts present suggestive of ATN/AIN
No hx of HTN, DM, lymphoma, multiple myeloma,
-F/u UA and urine electrolyte ordered 6 hours from previous --> if high/increasing consider 24hr urine to rule in nephrotic syndrome
Current indications to transfer to NMCSD for dialysis for oliguria/anuria. This may be provider dependent.
Rec transfer for dialysis IF meets following criteria:
--- severe hyperkalemia (>6 mEq or rapidly rising)
--- severe acidosis (pH <7.1-7.2)
--- refractory volume overload evidenced by increasing O2 demand (may trial diuretics if approaching this)
--- uremic complications (pericarditis, any unexplained AMS or may be considered if BUN >110-140)
Stable, CIWA ranging _ overnight. PAWSS score of _ on admission, no history of seizure or DTs. Exam continues to be reassuring for no signs of acute withdrawal. Last drink: _.
- Continue CIWA protocol
-- CIWA q2 hours
-- 1mg Ativan PRN for CIWA >8
-- 2mg Ativan PRN for CIWA >12
-- Folate 1 mg PO daily, Thiamine 100mg PO daily, adult multivitamin PO daily
- Librium 50mg TID x1 day (6AUG), then BID x1 day, then QD x1 day
#Neurologic
#Pain: Controlled
-analgesia
#Sedation: RASS
-sedative
#Encephalopathy:
#Mobility:
-ambulation goal
#Cardiovascular
#Pressors/Ionotropes:
#Arrythmias:
#Heart failure
#Acute coronary syndromes vs elevated troponin
#Respiratory
#Respiratory failure: Type I vs Type II
#ARDS: (P/F)
#Pneumonia: (Covid: 4C score)
-Vent settings: initial ACVC 6-8 cc/kg (ideal) R less than w/o ventilation PEEP 5 FiO2 100
-Sp goal
.chestpt
#Gastrointestinal
#Diet:
#Constipation: Last BM _
-Miralax Senna
#Transaminitis
#FEN/Renal/Genitourinary
#Fluids:
#Acidosis/Alkalosis:
#Electrolyte Imbalances:
Renal and GU pathology such as hematuria, renal calculi, and most commonly, acute kidney injury
#Hematologic
#Anemia:
#Thromboytopenia:
#Thromboses:
#Endocrine
#DM:
#Hypothyroidism:
#Infectious Disease
#Infection:
#Leukocytosis:
Cx
-CBC/CRP
Microbiology results: blood/sputum/urine cultures, gram stains, lab assays (C difficile PCRs, Legionella urinary antigen, etc.)
Antibiotics: current, prior, and planned durations
#Trauma, Surgical, Musculoskeletal, or Orthopedic
Diet:
Analgesia:
Sedation:
VTE PPx: Lovenox 40
Abx:
Head of bed: 30 degrees
Ulcer prophylaxis: Pantoprazole 40mg BID
Glycemic control: none
Bowel regimen: Miralax, Senna BID
T/L/D: 2 PIVs, foley
Code: Full
DPOA: Person (relationship) phone #
Dispo: ICU/SDU
You were admitted to the hospital for _. Your clinical exam has shown improvement with symptomatic treatment. Your labs have not been abnormal during admission. No new imaging completed on this admission; your recent imaging showed no concerning abnormalities. We sent out for cultures that have not yet resulted, however if these results are abnormal we will update you. You will need to follow up with your medical team in the next_ for continued monitoring. It can be several days to weeks before anticipated recovery. Can use Tylenol or Motrin for pain control.
During your stay there was no change to chronic medications, please continue to take the recommended doses until you follow up with your PCM:
You will be discharged with _ for _and _for _.
Follow-Up:
1) Please bring this paperwork with you to all scheduled follow-up appointments.
2) Please schedule or go to your follow-up appointments regarding this admission as above.
3) Please arrive 15 minutes early to all scheduled follow-up appointments.
4) Please create a list of medications/supplements/herbals you are taking along with the dose and how often you are taking it.
5) Please follow the instructions for your medications as prescribed above for the full course of time indicated. Do not make any changes to your medications unless directed by a physician.
6) Please seek care at the nearest Emergency Department of you experience dizziness, confusion, weakness, severe shortness of breath, chest pain or any other life threatening or concerning symptoms.
7) Diet: foods that are palatable, good intake is a priority at this time.
8) Activity: gradually increase as tolerated.
Discharge Condition:
On discharge, the patient was afebrile, hemodynamically stable, well-appearing, tolerating PO, ambulating and voiding normally. Follow up was arranged prior to discharge. All questions were answered and the patient verbalized understanding of the medical treatment plan and voiced agreement.