Note Report Sample:

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NOTE

S:

She is here for a re-check of weight.  She is being seen on a chronic basis for her failure to thrive.  Her normal weight is around 112.  She is down to 95.  Her pulse is 80.  Blood pressure is 110/68.  She has met a new friend and is enjoying his company.  He is also helping out with things around the house and she appreciates that very much.  She has gone to the graduation of her daughter from high school and her son from middle school.  Their father came to the son’s ceremony but not his daughter’s, which was her graduation from high school.  This had a huge impact on the family.  Her son has actually bitten Daniel again and fortunately did not draw blood this time, but they are definitely having difficulties.  She is trying to eat more but finding it difficult.  Her back is really bothering her.  She has had physical therapy but really has not noted any real improvement thus far.  She was suggested to try Pilates, which she is doing daily.  The pain is worse after working for several days and, although she had the injury on the left, it radiates all the way through to the right.  At the end of the week, she has difficulty even walking around in the mall.  She takes Naprosyn and Prilosec for her pain.  She notes a slight improvement.  She has no bowel or bladder symptoms but the pain radiates into her posterior thigh and makes her knee joint feel unstable.        

ROS:
Is listed in the HPI or otherwise negative.  She has no known drug allergies.  Medications are reviewed.  See medication sheet.  
PMH: Is reviewed.  No changes. 
SHX:

Social history is reviewed.  No changes, except as listed in the HPI.

PE:

This is a well-appearing thin middle-aged female.  She has slight exophthalmus, anicteric and pupils are equal round and reactive to light.  She is very thin appearing with very little musculature.  Her veins are clearly visible.  She has no thyromegaly.  Chest is clear to auscultation bilaterally.  Cardiovascular is regular rate and rhythm.  Her abdomen is scaphoid but soft with audible bowel sounds, is nontender and without organomegaly.  Her extremities are warm and well perfused.  There is no edema.         

A&P:

1. Reactionary depression.  She is on Lexapro, taking Xanax only as needed.  This seems to be improving her mood.

2. Anxiety. Please see #1.

3. Low back pain, herniated disc at L4-L5.  She continues to see physical therapy. Unfortunately, though, she is not getting a lot of improvement.

4. Varicose veins.  She is trying support pantyhose.  At the end of the day, especially when she has worked for a couple days in a row, she has deep, aching pain in her legs.

5. Hemorrhoids.  No symptoms.

6. Irregular menses.  She has perimenopausal.

7. Failure to thrive, weight loss.  She was encouraged to eat three meals and three snacks a day to include dense foods, such as ice cream and nuts.  She expressed understanding.

8. Osteopenia.  She continues to take her vitamin D for her vitamin deficiency.  She is also taking Actonel.  She has no esophageal problems, but she does need lab work done in August.  She was agreeable with the above-instructed plan.  Risks, benefits and side effects of medication and treatments were discussed, and she will follow up as suggested.