Name: Gottrocks

DOB:

CHIEF COMPLAINT:

The patient is here for follow up appointment after her session of radiation therapy with Dr. Sindhu,
oncologist.

HPI-ROS:

The patient presents today for her follow up visit after a month from the last encounter. She narrated
that she is gaining weight. Moreover, she reports that she completed her radiation therapy and
experiencing mild nausea but denies vomiting.

Medical reports have been obtained and reviewed from Dr. Sindhu, oncologist that she completed 28
sessions of radiation therapy and she will be subject to chemotherapy (Keytruda) twice a week for a
month.

The patient suffers from these chronic conditions: Chronic obstructive pulmonary disease and
hypertension.
The patient undergone these surgical procedures: Percutaneous coronary intervention, cardiac
pacemaker insertion at the left anterior descending artery, bronchoscopy with biopsy at the right lung.

REVIEW OF SYSTEMS:

General: Generally healthy, no change in strength or exercise tolerance.

Head: No headaches, no vertigo, no injury.

Eyes: Normal vision, no diplopia, no tearing, no scotoma, no pain.

Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.

Nose: No epistaxis, no coryza, no obstruction, no discharge.

Mouth: No dental difficulties, no gingival bleeding, no use of dentures.

Neck: No stiffness, no pain, no tenderness, no noted masses.

Heart: No chest pains, no palpitations, no syncope, no orthopnea

Chest: No dyspnea, no wheezing, no hemoptysis, no cough.

Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no

emesis, no melena.

GU: No urinary urgency, no dysuria, no change in nature of urine.

Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesia or
numbness.

Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.

Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.

PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE

General: Awake, alert, and oriented in no acute distress. Slower cognition during the visits.

Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.

Chest: Diminished breath sounds bilaterally.

ASSESSMENT

(C34.91) Malignant neoplasm of unspecified part of right bronchus or lung.

(J44.9) Chronic obstructive pulmonary disease, unspecified.

(I25.10) Atherosclerotic heart disease of native coronary artery without angina pectoris.

(Z95.0) Presence of cardiac pacemaker.

(Z68.24) Body mass index (BMI) 24.0-24.9, adult.

(I10) Hypertension.

PLAN

1. For pacemaker check, she will visit Dr. Elliot, cardiologist for evaluation and treatment.

2. For malignant neoplasm of unspecified part of right bronchus or lung, we tackle the possibilities to do
advance directives such as gaining her permission to allow nasogastric tube insertion, resuscitation
intervention or other heroic measures. All of her questions were answered. She did not give any
feedback with the treatment plan during the visit but she verbalized that she needed to discuss it with
her son before making a decision.

3.For living status, she is currently residing to a retirement home. We discuss that she needs to be
shifted to an assisted living specifically with Prestige, a nursing facility for assisted living residents. She
agress with it and referral to be send.

4. For transportation needs, she will be set up to ViCaP, a non-profitable organization that will help her
out for transportation needs, medical treatments and purposes.
5. For a follow-up appointment, she will be seen after a month.

The total time spent for this encounter is 6-7 minutes with more than 70% of the time spent for
counselling.

I, Mark Carnett, personally performed the services described in this documentation, as scribed by Eunice
Agustin, RN, in my presence, and it is both accurate and complete.

Name: Katie
DOB:

CHIEF COMPLAINT:

The patient is here with chief complaint stomach problems.

HPI-ROS:

The patient presents today for her stomach problem, it worsens when she is not eating but relieves once
she ingests food. She reports that she frequently burping a lot and having pain from her stomach going
up around her chest. Her symptoms started 3 weeks ago. She denies any fever or chills or taking any
medication during the visit.

REVIEW OF SYSTEMS:

General: Generally healthy, no change in strength or exercise tolerance.

Head: No headaches, no vertigo, no injury.

Eyes: Normal vision, no diplopia, no tearing, no scotoma, no pain.

Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.

Nose: No epistaxis, no coryza, no obstruction, no discharge.

Mouth: No dental difficulties, no gingival bleeding, no use of dentures.

Neck: No stiffness, no pain, no tenderness, no noted masses.

Heart: No chest pains, no palpitations, no syncope, no orthopnea

Chest: No dyspnea, no wheezing, no hemoptysis, no cough.

Abdomen: Remarkable for epigastric pain.

GU: No urinary urgency, no dysuria, no change in nature of urine.

Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesia or

numbness.

Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.

Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.

PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.
OBJECTIVE

General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.

Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.

Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use of
accessory muscles of respiration.

Abdomen: Remarkable pain upon palpation in epigastric region.

ASSESSMENT

(K21.9) Gastro-esophageal reflux disease without esophagitis

PLAN

1. For medication, I prescribed omeprazole 20 mg for 14 days, no refills. I educated her that she will feel
a lot better after 3-4 days. She can take it with or without food.

2. For food ingestion, I advised her to stop chewing gums, lessen her caffeine and soda intake. She
agrees with the plan.

3. If pain persist after the medication, I advised her to do a follow up appointment. We discussed the
possibilities that she might be referred to a gastroenterologist for upper endoscopy or subject for blood
works. She verbalizes understanding.

I, Mark Carnett, personally performed the services described in this documentation, as scribed by Eunice
Agustin, RN, in my presence, and it is both accurate and complete.