Sample Chart Note #3
| RE: | Debra Jones |
| DATE: | 12/01/10 |
| MR: | 240804 |
| DOB: | 12/01/65 |
SUBJECTIVE: The patient is a 43-year-old white female who has had an exacerbation of her chronic cervical pain since last Friday. She thinks it might be secondary to lifting a bag of groceries. She has had good success in the past with seeing a chiropractor in this situation.
Physical therapy has generally not been helpful in the past. She takes Prozac 20 mg a day and Darvocet N-100, which she uses occasionally. She reports no allergies.
EXAMINATION: Vital Signs: Pulse 72, blood pressure 110/82, weight 196-1/2 pounds. Neck: Tenderness in the right posterior cervical area with no spasm.
ASSESSMENT:
1. Chronic cervical pain.
2. Chronic depression.
PLAN: Darvocet N-100, #10 only with no refills. Naprosyn 500 mg one p.o. b.i.d. as needed. Referral to chiropractor.
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