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HPI
asthma
asthma triggers social factors er visits or hospitalizations number of times sx per week missed school or work secondary to symptoms peak flow meter controller meds using quick relief meds - how often needed waking at night 2nd asthma- how often sxs due to asthma interfere with activity how often PEFR % predicted
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HPI
depression
anhedonia wght loss/gain guilt insomnia suicidality libido decreased interest energy concentration
dx/back pain
No injury. Has past hx of previous low back pain. No radicular pain down either leg. No problem with bowels, bladder retention/constipation or loss of control. No weakness in legs b/l. No hx of kidney stones. No unrinary symptoms. Relieved by rest. Exacerbated by . Medications relief. Past w/u treatment . Night pain.
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HPI
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HPI
irritable bowel-alarms
Has no bloody stools, black stools. Has no nocturnal symptoms. Has no recent antibiotic use. Has no unintentional weight loss. Has no family hx of colon cancer. ?abd pe findings?
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HPI
Abscess
Patient C/O extremely painful area. Notes swelling and erythema. States the pain is increasing, as it inc. in tenderness.
HPI
2. Extended HPI
At least 4 elements of HPI (location, quality, severity, duration, timing, context, modifying factors, associated signs & symptoms), or the status of at least 3 chronic or inactive conditions
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HPI
The patient complains of RUQ abdominal pain, on and off 2 weeks of evolution, the pain is colic type with abdominal distention, without rhythm RUQ ABDOMINAL and periodicity, get worse with food , the severity is 7 in a scale 1 to 10 PAIN and radiates to the back to interscapular area is associated to constipation, nauseas, and vomiting, denies diarhea or melena.
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HPI
dx: URI
Patient notes a runny nose, head congestion, and some post-nasal drip.
dx: Cough/Cold
Patient notes cough and cold symptoms including runny nose, dry cough, low-grade fever, and some discolored rhinorrhea. Notes feeling run down and has some sinus congestion. No frank shortness of breath or rigors.
Newborn visit 1
Concerns and questions None Addressed 40 week born to a yo G 1 P 1 mother Hospital & Prenatal source NSVD Labor for Hours Blood type: Maternal Child Birth weight Discharge weight Bilirubin screening Pediatrics Newborn hearing screening normal Hep B vaccine given prior to discharge Prenatal complications NONE Neonatal complications NONE Postnatal complications NONE
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HPI
HPI
meh
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HPI
Newborn visit 1
Concerns and questions None Addressed 40 week born to a yo G 1 P 1 mother Hospital & Prenatal source NSVD Labor for Hours Blood type: Maternal Child Birth weight Discharge weight Bilirubin screening Pdiatrics Newborn hearing screening normal Hep B vaccine given prior to discharge Prenatal complications NONE Neonatal complications NONE Postnatal complications NONE
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HPI
Adderal eval
No problems related to adderal use, no headache no abdominal pain no neuro changes
Abdominal Pain HPI bette
Duration of pain, location of pain; characteristics of pain (diffuse, burning, crampy, sharp, dull); constant or intermittent; frequency. Effect of eating, defecation, urination, movement. Characteristics of last bowel movement. Pediatrics Relation to last menstrual period Relationship to meals. What does the patient do when the pain occurs?
Adenopathy HPI
Duration of generalized or regional adenopathy. Fever, pattern, spiking fevers, relapsing fever, rash, arthralgias. Sore throat, nasal discharge, cough, travel history. Animal exposure (cat scratch, kittens). Localized Pediatrics trauma or skin infection, exposure to tuberculosis, blood product exposure. Conjunctivitis, recurrent infections.
asthma environment
How many people in household Any Smokers Smokers elsewhere exposure Pets at home/elsewhere Home heating system Frequency of air filter change if forced air Air conditioning? Gas stove or electric Use exhaust fan during cooking Leaky spots or mildew in the home What type of window covering are in the home Are they cloth or metal or wood Pediatrics Home basement Is the basement damp Plants in the home Wall to wall carpeting What flooring is in the bedroom What type of pillow foam or down Is the mattress covered House/room use of an air purifier House use of air sprays or fresheners
Asthma hx new
Birth Hx Prematurity Oxygen use neonatally Family hx of atopy (Who/What) Age when asthma sx started/diagnosed: Total hospital admits through life: Number of hospital admits last 12 months: Any Intubations?: Total asthma ER visits in life: Number of ER visit in last 12 months: Number of prednisone episodes in past 12 months: Is there a seasonal Pediatrics worsening/when?: Asthma Triggers Change of Weather Cold Air URI Number of colds in last 12 months: Length of colds when they occur: Do colds “settle in chest†frequently?: How long does an MDI last Are sx getting better worse or same?:
Pediatrics
Pediatrics
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HPI
HPI
HPI
HPI
Pediatrics
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HPI
Asthma interm hx
Asthma Sx number of days in the past Month: Awakening from sleep or wheezing at noc Couging or wheezing at noc in sleep Cough or wheeze earing in am Cough or wheeze during day without exercise or playing Couth or wheeze with exercise or playing Needed albuterol/xopenex Prednisone days in last month Missed school due to asthma
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HPI
Atopic house review
Newer house forced air, changes filters monthly No carpet metal drapes cleaned monthly No areas with leaks or peeling paint No basement
dermatitis soaps
No change in soaps, detergents, fabric softener, and no known irritant on skin. Has not been involved with irritative chemicals. No one else at home Pediatrics with a similar rash
Diet obesity review
Drinks mostly water, moderate juice occasional pop. Discussed change to calorie free. Cut back on eating out but still does fry at home periodically. Discussed baking and broiling more, removing skin on chicken. Very active, not couch potato.
Enuresis
Long hx of nocturnal enuresis 2-3 times a week. No daytime problems Goes to bed at 10 pm usually stops liquids at 7-8 pm. Tried reward systems. No negative repercussions No frequency, urgency, dysuria. No Pediatrics hx of UTIs in the past. No prior problems with constipation or diarrhea, no problems with lactose now
HPI
Enuresis
Long hx of nocturnal enuresis 2-3 times a week. No daytime problems Goes to bed at 10 pm usually stops liquids at 7-8 pm. Tried reward systems. No negative repercussions No frequency, urgency, dysuria. No Pediatrics hx of UTIs in the past. No prior problems with constipation or diarrhea, no problems with lactose now
HPI
Had extensive discussion about the vaccine and whether it is good. Discussed regular vs H1N1 vaccines, Discussed spray vs injectable Flu vaccine discussion vaccine, Discussed live vs killed virus vaccine. Discussed CDC recommendations. Answered all of parents and children's questions. Parents opted to receive vaccines at this time.
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HPI
HPI
HPI
Pediatrics
Pediatrics
New rash for about 1 week. Seems to have been getting worse, Began on face and spread down. Seems to be itching him No new foods no new soaps (Huggies soap) no new detergent (Dreft) No new fabric softener No Pediatrics one else in house with rash. Has been using baby oil for moisture without improvement. No vomitting, No diarrhea. No URI sx, no fever. Tried benedry without imrprovement.
HPI
Rash
HPI
Nature of symptoms: Quality of symptoms: Severity of symptoms: Symptom or pain eval Frequency of symptoms: Duration of symptoms: Modifying factors: Other Pediatrics interim history:
PHQ-9
Patient Health Questionnaire (PHQ-9) OVER THE LAST 2 WEEKS, how often have you been bothered by any of the following problems? Responses: 0-Not at all, 1-Several Days, 2-More than half the days, 3Nearly every day 1. Little interest or pleasure in doing things: 2. Feeling down, depressed or hopeless: 3. Trouble falling or staying asleep, or sleeping too much: 4. Feeling tired or having little energy: 5. Poor appetite or overeating: 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down: 7. Trouble concentrating on things, Family Medicine such as reading the newspaper or watching television: 8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual: 9. Thoughts that would be better off dead, or of hurting yourself in some way: If you have checked off ANY problem on this questionnaire so far, how DIFFICULT have these problems made it for you to do your work, take care of things at home, or get along with other people? Severity (Total) Score:
CUXOS Anxiety Scale
CUXOS Anxiety Scale: (0 = not at all true; 1 = rarely true; to = sometimes true; 3 = often true; 4 = almost always true) During the PAST WEEK, INCLUDING TODAY: 1. I felt nervous or anxious: 2. I worried a lot that something bad might happen: 3. I worried too much about things: 4. I was jumpy and easily startled by noises: 5. I felt keyed up or on edge: 6. I felt scared: 7. I had muscle tension or muscle aches: 8. I felt jittery: 9. I was short of breath: 10. My heart was pounding or racing: 11. I had cold, clammy hands: 12. I had a dry mouth: 13. I was dizzy or light headed: 14. I Family medicine felt sick to my stomach (nauseated): 15. I had diarrhea: 16. I had hot flashes or chills: 17. I urinated frequently: 18. I felt a lump in my throat: 19. I was sweating: 20. I had tingling feelings in my fingers or feet: SCORE: 0-10 not anxious 11-20 minimal anxiety 21-30 mild anxiety 31-40 moderate anxiety 41 and above severe anxiety (Zimmerman, M., Chelminski, I., McGlinchey, J.B., & Posternak, M.A. A clinically useful depression outcome scale. Comprehensive Psychiatry, 2008, 49, 131-140.)
Diabetes check
Patient notes feeling well without any specific complaints. Checks BS regularly. Runs in good range. Checks BP and runs in good range as well. Has had eye exam in the past year. Does nightly foot checks.
Diabetes check
Patient notes feeling well without any specific complaints. Checks BS regularly. Runs in good range. Checks BP and runs in good range as well. Has had eye exam in the past year. Does nightly foot checks.
dx: Cough/Cold
Patient notes cough and cold symptoms including runny nose, dry cough, low-grade fever, and some discolored rhinorrhea. Notes feeling run down and has some sinus congestion.
HPI
wt loss f/u
follow up on weight loss program with use of appitite suppresant + balance deficient diet+ excercise . Pt has no new medical issue since last visit. Appitiate suppressed fairly most of time. not experiencing reamrkable side effect with Phentermine , no CP, no SOB or palpitation, no focal neural IM symptom. no remarkable headache or dizziness. No legs edema . No panic attack. Sleep as usual. Exercise as good as can . little more energetic . mild sleep disturbance, mild constipation . lately more hungery during evening hours.
HPI
Pt. complaints of on/off runny nose, sinus congestion ,sneezing with postnasal dripping. Also dry cough,tickle at throat and clear nasal discrage. ALLERGIES: SINUS Denies any fever or pain. This happens during certain periods of the years worse than others. Also eyes itchiness on/off.
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HPI
Diabetes check
Patient notes feeling well without any specific complaints. Checks BS regularly. Runs in good range. Checks BP and runs in good range as well. Has had eye exam in the past year. Does nightly foot checks.
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HPI
hx: Pain (PQRST)
Pain: Quality: Region: Severity: Timing: Aggravated by: Relieved by: Pain score (out of 10): Other info:
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HPI
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HPI
nfp
Patient was seen by Fertility Care Practitioner for instruction/education on Creighton Method natural family planning. Refer to paper follow-up form for documentation of educaton done today.
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HPI
hx: Pain (PQRST)
Pain: Quality: Region: Severity: Timing: Aggravated by: Relieved by: Pain score (out of 10): Other info:
HPI
Patient c/o insidious onset chronic abdominal pain. Pain is constant, colicky in nature, associated with occasional nausea and vomiting. He describes normal abnormal bowel movements He doesn't have specific dietary or food intolerance. Aggravating factors, certain fatty food. ABDOMEN/ PELVIC Reliving factors for pain are medication and rest. Patient has hasn't been evaluated by Gastroenterologist. Past H/O abdominal/Pelvic surgery. absent. Gives denies H/O chronic ETOH use. Patient has constipation diarrhea. Patient is also c/o painful coitus. No H/O physical or sexual abuse.
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HPI
CTS
Presenting symptoms include decreased grip strength, difficulty to form a fist, loss of sensation in fingers, nocturnal parasthesia in fingers and palm of hand and unable to grip small objects. There was noradiation to wrsit and forearm. Symptoms are aggravated by driving, repetitive work. There are no reliving factors. Associated symptoms include numbness, parasthesia, swelling and stiffness of wrist joint.
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HPI
Ptname
%FNAME %LNAME is a %AGE year old %sex with
PAIN MANGEMENT
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HPI
14 TO 16YR ANTICIPATORY
ANTICIPATORY GUIDANCE: SOCIAL: CONFIDENTIALITYY,PEER GROUP PRESSURES-Y ,MOOD SWINGSY,DEPENDENCE VS INDEPENDENCE-Y,ESTABLISHING OWN VALUES-Y, SOCIAL MISCONDUCT RESULTING FROM FAMILY DYSFUNCTIONS-Y,FUTURE PLANS-Y,STAY IN SCHOOLY,LOVE LIFE-Y PARENTING: ESTABLISH FAIR,NEGOTIABLE RULES-Y,ALLOW DECISIONS-Y,PROVIDE SUPPORTY,ENCOURAGEMENT-Y,MONEY,ALLOWANCE-Y,PROMOTE MUTUAL RESPECT-Y,RESPECT PRIVACY-Y. HEALTH: DENTAL CARE-Y,PERSONAL HYGIENE-Y,FLUORIDEY,MENSTRUATION-Y,BREAST/TESTICULAR SELF EXAMY,SMOKING-Y,SECOND HAND SMOKE-Y,USE SUNSCREENY,TICK PREVENTION-Y. SEXUALITY: PREPARE FOR PHYSICAL CHANGES-Y,BIRTH CONTROL-Y,STD-Y,SEXUAL RESPONSIBILITY-Y. INJURY PREVENTION: SEAT BELTY,ALCOHOL/DRUG USE-Y,BICYCLE HELMETS-Y,PROTECTIVE DEVICES IN SPORTS-Y,WATER SAFETY-Y,SMOKE DETECTOR/ESCAPE PLAN-Y,FIREARMS(RISK/SAFE STORAGE)-Y.
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HPI
1. Brief HPI
1-3 elements of HPI (location, quality, severity, duration, timing, context, modifying factors, associated signs & symptoms)
CAD Checklist
Coronary artery disease checklist - Drug therapy to lower cholesterol: LDL < 100: History of MI: ACE or ARB post MI: Blood pressure < 130/80: Family Medicine ASA prophylaxis: Family Medicine
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HPI
IM
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Diabetes checklist
HgbA1c - Foot exam with monofilament - Retinal exam - Urine microalbumin/creatinine ratio - Total cholesterol - LDL - HDL Triglycerides - TSH - Aspirin prophylaxis - ACE Inhibitor -
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HPI
NH - boiler plate
Nurse's notes, vital signs, and medications reviewed in the nursing home chart.
Family Medicine
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HPI
USPSTF PSA
Discussed recent USPSTF recommendations regarding prostate cancer screening. We will forego this at this time.
Family Medicine
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HPI
Brace
Denies having back brace.
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HPI
PAIN CONTINUES
Pt reports pain continues with limited daily activites and mobilities. States doing good with current medication regimen in controlling pain and is trying to do exercises and activities that will help relief pain symptoms.
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HPI
SUICIDAL
Patient denies any suicidal thoughts, ideations, or plans.
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HPI
14 TO 16YR ANTICIPATORY
ANTICIPATORY GUIDANCE: SOCIAL: CONFIDENTIALITYY,PEER GROUP PRESSURES-Y ,MOOD SWINGSY,DEPENDENCE VS INDEPENDENCE-Y,ESTABLISHING OWN VALUES-Y, SOCIAL MISCONDUCT RESULTING FROM FAMILY DYSFUNCTIONS-Y,FUTURE PLANS-Y,STAY IN SCHOOLY,LOVE LIFE-Y PARENTING: ESTABLISH FAIR,NEGOTIABLE RULES-Y,ALLOW DECISIONS-Y,PROVIDE SUPPORTY,ENCOURAGEMENT-Y,MONEY,ALLOWANCE-Y,PROMOTE MUTUAL RESPECT-Y,RESPECT PRIVACY-Y. HEALTH: DENTAL CARE-Y,PERSONAL HYGIENE-Y,FLUORIDEY,MENSTRUATION-Y,BREAST/TESTICULAR SELF EXAMY,SMOKING-Y,SECOND HAND SMOKE-Y,USE SUNSCREENY,TICK PREVENTION-Y. SEXUALITY: PREPARE FOR PHYSICAL CHANGES-Y,BIRTH CONTROL-Y,STD-Y,SEXUAL RESPONSIBILITY-Y. INJURY PREVENTION: SEAT BELTY,ALCOHOL/DRUG USE-Y,BICYCLE HELMETS-Y,PROTECTIVE DEVICES IN SPORTS-Y,WATER SAFETY-Y,SMOKE DETECTOR/ESCAPE PLAN-Y,FIREARMS(RISK/SAFE STORAGE)-Y.
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HPI
BB
BB VA BIEN PAS DE CRAINTES DE LA PART DES PARENTS
HPI annual
55- year- old Caucasian male with a smoking history presents for a general physical exam. He recently had a BP of 150/90 mm hg at a health fair four months ago. He is concerned about heart disease since one of his friends was recently diagnosed with heart disease and had to undergo bypass surgery. He is here to receive a full physical because he wants to work on preventing heart disease and get his blood pressure evaluated in order maintain a healthy level.
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dx: Cough/Cold
Patient notes cough and cold symptoms including runny nose, dry cough, low-grade fever, and some discolored rhinorrhea. Notes feeling run down and has some sinus congestion. No frank shortness of breath or rigors.
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HPI
hx:ob/gyn
Age at Menarche: Age at Menopause: LMP: G P Cycle: Length of period: fp Days of flow: Hormones: Breast SE: Last Pap/Mammo: Any abnormals:
INTAKE Form/HPI
Our nurse transcribes the answers from the patient or their accompanying care provider to the following questions. (Further followup and or clarification after physician review is shown in double parentheses.) 1. Has there been a change in your PCP? (NO, Current PCP is:) 2. How is your health? 3. Have you had any new hospitalizations, surgeries or ER/Urgent Care visits since your last office visit? (CIRCLE YES OR NO). If yes, please describe: 4. Since your last visit, have you had any prescribed changes in medications, run out of any, or are otherwise aware that you are not taking them as prescribed? (YES or NO) Please list any changes: 5. Do you need any medications to be refilled today? (YES or NO) Please list: 6. Have you had any new lab studies, radiology or other diagnostic procedures since your last visit? (YES or NO) Please list: 7. Do you have any new problem you want to discuss with the doctor today? (YES or NO) Please list: 8. Is there any other information to update on your file? (YES or NO) Please list: 9. Are you using any NSAIDS? Such as: ibuprofen, Advil, Motrin, Aleve, Naprosyn, Aspirin (other than 81 mg per day for your heart), or other prescription NSAID? (YES or NO) Please list: 10a. Are you PRESCRIBED a dietary prescription for restrictions of fluids, salt potassium, phosphorous, carbohydrates, fat, or any other dietary concern? (YES or NO) Please list: b. Are there dietary restrictions you follow that are NOT prescribed? (YES or NO) Please list: 11. Were you asked to bring in a diary for blood pressure, weight, medication administration, pain levels, or for any other purpose? (YES or NO) Please list: 12. Do you use tobacco or marijuana? (YES or NO) 13. Has there been a significant change in the health of your family members who are related to you by blood? (YES or NO) Please list: 14. Have you been around family members, friends or other close contacts that have recently been ill? (YES or NO) Please list:
Focused Diabetes History
Patient stated that diabetes is generally well controlled with a glucose range of ____. Patient understood that if his/her blood glucose levels were poorly controlled, that would delay wound healing and put him/her at increased risk for infection and other complications. He/She does not report hypoglycemic reactions since the last visit. No evidence of diabetic nephropathy that might alter use of medications. Patient is self-monitoring his/her blood glucose daily. The last HbA1c was ____ on date___.
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HPI
integrative medicine
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HPI
Therapy Progress Notes
Does the patient have any life changes, triggers, or stressors since the last visit? Does the patient have any plan to cope with these changes, triggers, or stressors? New skills learned in counseling since last appointment: New skills applied in life: Are they helping? Next short term goal: How often is the patient attending counseling? Pt's progress since last visit: Other medical conditions that need treatment: Assessment: Plan: Counselor Name and Initial: Telephone Number:
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HPI
depression
anhedonia wght loss/gain guilt insomnia suicidality libido decreased interest energy concentration
Eating Disorder
!. What has been your highest weight? --2. What has been your lowest weight? --3. What do you want to weigh? --4. Does your weight affect the way you feel about yourself? Y / N --5. Do you ever eat in secret? Y/N -6. Do you worry you have lost control over how much you eat? Y/N --7. How much has your weight changed in the past 3 months? --8. Do you believe yourself fat when others say your are too thin? --9. Have any Pediatrics members of your family suffered with an eating disorder? What changes have occurred in your life over the past year? -- Do you have any chronic health issues? --Anxiety/depression/OCD etc? What is your typical eating pattern in a day? -- What is your typical activity/exercise routine? ie. dancing, gymnastics, wrestling, school sports, modeling/acting, after school activites/clubs, etc
depression/anxiety
1. Anhedonia (lack of joy or pleasure):? -- 2. Weight loss/gain ? -- 3. Sleep changes: insomnia/night time wakening?-- 4. Excessive daytime sleepiness?-- 5. Guilt ?-- 6. Decreased Interest?-- 7. Decreased energy? -pediatrics 8. Concentration/focus diminished?-- 9. School performance---- 10. Use of alcohol/pot/nicotine/street drugs? 11. Self harm? cutting/suicidal ideation? 12. What have you tried to help you cope/improve your mood?
eating disoreder
Females: Age of Menarche: Regualr/irregular/absent cylce --- ALL: Sexually active? Y/N Hx of Abuse? Y/N -- HEENT: Fatigue? Y/N -Insomnia Y/N-- Early morning awakening Y/N -- Headaches Y/N -e Fevers? Y/N -- NIght sweats Y/N -- Hair loss/thinning hair? Y/N --Mouth sores? Y/N -- Dysphagia? Y/N -- Bldg gums/epitaxis/easy bruising? Y/N - Light headness/dizziness? Y/N -- Dysnpnea/cough? Y/N -- Heart palpations/chest pain? pediatrics GI:Nausea/Vomiting/HEartbrun/GERD/Earlysatiety/Constipation/Diarrhea /Bloating? GU:Increased urination/dysuria/urgency? Y/N -- MS: joint swelling/reddeness/stiffness/pain Y/N Endocrine: Hyporthermia? Y/n Dry skin Y/N Periperheral edema? Y/N -- Yellow skin/skin rash/itchy skin Y/N -- PSCY: trouble concentrating/anxiety/stress/anhedonia/ anger/irritability/lonliness/suicidal/homocidal/self injurious thoughts? Y/N
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HPI
Pulmonary
The patient is a ___ year old ___(Race- M or F). Last clinic visit was___. Changes/No changes made in medical management at last office vist include____. Symptoms include_____. Onset was gradual/sudden. The symptoms occur ( daily, weekly, monthly ). Patient describes this as (mild, moderate, severe). Symptoms are exacerbated by___. Symptoms are relieved by ______. Current treatment of ____. Compliance is ___ with ___ tolerance. No recent exacerbation/infections noted.
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1st Tri OB Labs
FIRST TRIMESTER OB LABS:
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No Complaints
Patient notes feeling well without any specific complaints.
WELLCHILD8 yrs
Illnesses/Accidents/Problems/Concerns since last visit: Developmental milestones: eats breakfast daily -- yes; doing well in school -- yes; has one or more close friends -- yes; seems rested when awake -- yes; handles stress, anger, frustration appropriately -- yes; gets some physical activity daily -- yes. Diet: Elimination: Sleep:
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Comments By Uploader
INTERNAL MEDICINE
Depression questionnaire