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I have had diarrhea for 3 days.
Subjective. Chief complaint.
Creatinine level of 1.5
Objective. Lab value.
Self-employed as an accountant
Subjective. Social history.
Temp 99.2F
Objective. Vitals.
Pain is sharp, constant and non-radiating.
Subjective. HPI. OLDCARTS.
A1C 6.3%
Objective. Point of care testing.
Patient's parent concerned about spit-up after every feeding.
Subjective. Chief complaint.
Take 600 mg of Ibuprofen every 8 hours as needed for knee pain - take with food.
Plan. Treatment.
I sprained my ankle last week, but I'm here to talk about my headache.
subjective. Chief complaint.
Pt is adopted
subjective. family history.
Home pregnancy test was positive 3 days ago.
Subjective. HPI.
Frequent cough.
Subjective or objective, depending
Cholecystectomy 12 years ago in Nicaragua.
Subjective. Surgical history.
Smokes 1 pack day for the past 10 years.
Subjective. Past social history.
Sx interfering with work.
Subjective. HPI.
Is self-employed as an accountant.
Subjective. Social history.
Abdomen is soft, non-tender with no rebound or guarding.
Objective. Exam.
2 pregnancies, 1 TAB, and 2 live births
Subjective. PMH, OB/GYN.
red bumps around mouth
subjective or objective, depending
Father had a heart attack at age 52.
Subjective. Family history.
objective. point of care testing.
Sore throat. Likely viral URI. Considering allergy component given itchy, watery nose and eyes as well as itchy ears. Doubt group a streptococcus given negative rapid swab.
Assessment. Differential diagnosis.
Pitting edema (3+) L lower extremity
Objective. Exam.
Benadryl is a medication that is used to treat your current rash/allergy. One of the most common side affects is sedation so please do not drive or do activities that may hinder your ability to remain alert.
Plan. Pt education.