SUBJECTIVE:
- Reason for visit: Patient presents with persistent cough and shortness of breath. "I've been coughing for the past two weeks and it's getting harder to breathe, especially at night." History of presenting complaints: The cough started after a recent cold. No other therapies have been trialed. Previously seen at the local urgent care for similar symptoms last year.
RELEVANT PAST MEDICAL HISTORY:
- Past medical history: Asthma diagnosed in childhood, Hypertension
- Medications: Albuterol inhaler, Lisinopril
- Social history: Non-smoker, occasional alcohol use
- Allergies: Penicillin
REVIEW OF SYSTEMS:
- Constitutional symptoms: Fatigue
- Eyes: No symptoms
- Ears, Nose, Mouth, Throat: Nasal congestion
- Cardiovascular: No symptoms
- Respiratory: Cough, Shortness of breath, No smoke exposure
- Gastrointestinal: No symptoms
- Genitourinary: No symptoms
- Musculoskeletal: No symptoms
- Integumentary (Skin): No symptoms
- Neurological: No symptoms
- Psychiatric: No symptoms
- Endocrine: No symptoms
- Hematologic/Lymphatic: No symptoms
- Allergic/Immunologic: No symptoms
OBJECTIVE:
- Vitals: BP 130/85, HR 78, RR 20, Temp 37°C
- Physical examination: Lungs - wheezing noted bilaterally, Cardiovascular - normal S1 S2, no murmurs
- Investigations: Chest X-ray pending
ASSESSMENT & PLAN:
1. Asthma exacerbation, J45.901
- Assessment: Likely diagnosis is asthma exacerbation
- Differential diagnosis: Upper respiratory infection
- Investigations planned: Chest X-ray
- Treatment planned: Increase Albuterol inhaler use, start oral corticosteroids
- Relevant referrals: None
- CPT code for treatment rendered: 99213
2. Hypertension, I10
- Assessment: Hypertension, well-controlled
- Treatment planned: Continue Lisinopril
- Relevant referrals: None
- CPT code for treatment: 99213
Visit CPT code: 99213
Dr. Thomas Kelly, MD
Family Medicine
Green Valley Clinic
1 November 2024
Subjective (BOLD, ALL CAPS):
- [Reason for visit, Current issues (quote the patient's description of symptoms), history of presenting complaints etc (if applicable), all other trialed therapies, where they were previously seen for this issue (if applicable)]
Relevant Past Medical History:
- [Past medical history, previous surgeries (if applicable)]
- [Medications (if applicable)]
- [Social history (if applicable)]
- [Allergies (if applicable)]
Review of Systems (BOLD, ALL CAPS):
- Constitutional symptoms: [Symptoms like Weight change, Fever, Chills, Night sweats, Fatigue, Malaise]
- Eyes: [Symptoms like Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes]
- Ears, Nose, Mouth, Throat: [Symptoms like Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty]
- Cardiovascular: [Symptoms like Chest pain, Shortness of breath (SOB), Paroxysmal nocturnal dyspnea (PND), Dyspnea on exertion, Orthopnea, Claudication, Edema, Palpitations]
- Respiratory: [Symptoms like Cough, Sputum production, Wheezing, Smoke exposure, Dyspnea]
- Gastrointestinal: [Symptoms like Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn, Anorexia, Dysphagia, Hematochezia, Melena, Flatulence, Jaundice]
- Genitourinary: [Symptoms like Dysmenorrhea, Dysfunctional uterine bleeding (DUB), Dyspareunia, Dysuria, Urinary frequency, Hematuria, Urinary incontinence, Urgency, Flank pain, Changes in urinary flow, Hesitancy]
- Musculoskeletal: [Symptoms like Arthralgias, Myalgias, Joint swelling, Joint stiffness, Back pain, Neck pain, Injury history]
- Integumentary (Skin): [Symptoms like Skin lesions, Pruritis, Hair changes, Breast/skin changes, Nipple discharge]
- Neurological: [Symptoms like Weakness, Numbness, Paresthesias, Loss of consciousness, Syncope, Dizziness, Headache, Coordination changes, Recent falls]
- Psychiatric: [Symptoms like Anxiety/Panic, Depression, Insomnia, Personality changes, Delusions, Rumination, Suicidal ideation/Homicidal ideation/Auditory hallucinations/Visual hallucinations, Social issues, Memory changes, Violence/Abuse history, Eating concerns]
- Endocrine: [Symptoms like Polyuria, Polydipsia, Temperature intolerance]
- Hematologic/Lymphatic: [Symptoms like Bruising, Bleeding, Transfusion history, Lymphadenopathy]
- Allergic/Immunologic: [Symptoms like Allergic reactions, Auto-immune disorders]
Objective (BOLD, ALL CAPS):
- [Physical or mental state examination findings, including vitals and system specific examination (if applicable)]
- [Investigations with results (if applicable)]
Assessment & Plan (BOLD, ALL CAPS):
[1. Issue, problem or request 1 (issue, request or condition name only)], [ICD10 code for this issue]
- [Assessment, likely diagnosis for Issue 1 (condition name only)]
- [Differential diagnosis for Issue 1 (only if applicable)]
- [Investigations planned for Issue 1 (only if applicable)]
- [Treatment planned for Issue 1 (only if applicable)]
- [Relevant referrals for Issue 1 (only if applicable)]
- [CPT code for treatment rendered (if applicable)]
[2. Issue, problem or request 2 (issue, request or condition name only)], [ICD10 code for this issue]
- [Assessment, likely diagnosis for Issue 2 (condition name only)]
- [Differential diagnosis for Issue 2 (only if applicable)]
- [Investigations planned for Issue 2 (only if applicable)]
- [Treatment planned for Issue 2 (only if applicable)]
- [Relevant referrals for Issue 2 (only if applicable)]
- [CPT code for treatment (if applicable)]
[3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)], [ICD10 code for this issue]
- [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only)]
- [Differential diagnosis for Issue 3, 4, 5 etc (only if applicable)]
- [Investigations planned for Issue 3, 4, 5 etc (only if applicable)]
- [Treatment planned for Issue 3, 4, 5 etc (only if applicable)]
- [Relevant referrals for Issue 3, 4, 5 etc (only if applicable)]
- [CPT code for treatment (if applicable)]
Visit CPT code (for level and type of visit, document as first visit unless otherwise stated):
[Name of clinician], MD
Family Medicine
[Name of clinic/hospital]
[DATE]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
