Medical Specialty: Office Notes

Office notes.

Office Notes
Abnormal Stress Test
Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.
Cardiology Office Visit - 1
Sample cardiology office visit note.
Cardiology Office Visit - 2
Cardiology office visit sample note.
Chest Pain - Office Note
Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain
Constipation - 1
Patient complains of constipation. Has not had BM for two days.
Gen Med Office Note - 1
Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.
Headache - Office Visit
The patient with continued problems with her headaches.
Hip Pain
Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing
Induction of Vaginal Delivery
Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.
Myoclonic Epilepsy
Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.
Nephrology Office Visit - 1
Nephrology office visit for followup of microscopic hematuria.
Nephrology Office Visit - 2
Nephrology office visit for followup of CKD.
Normal Child Exam Template
Normal child physical exam template.
Normal ENT Exam
Sample normal ear, nose, mouth, and throat exam.
Normal ENT Exam - 1
Sample normal ear, nose, mouth, and throat exam.
Normal Female Exam Template
Sample/template for a normal female multisystem exam
Normal Female Exam Template - 1
An example/template for a routine normal female physical exam.
Normal Female Exam Template - 2
An example/template for a routine normal female physical exam.
Normal Female ROS Template
Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.
Normal Male Exam Template
Sample/template for a normal male multisystem exam.
Normal Male Exam Template - 1
An example/template for a routine normal male physical exam.
Normal Male Exam Template - 2
An example/template for a routine normal male physical exam.
Normal Male Exam Template - 3
An example/template for a routine normal male physical exam.
Normal Male Exam Template - 4
An example/template for a routine normal male physical exam.
Normal Male ROS Template - 1
An example/template for a routine normal male ROS.
Normal Newborn H&P Template
Template for History and Physical for a newborn.
Normal Newborn Infant Physical Exam
Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.
Normal Physical Exam Template
An example of a physical exam
Normal Physical Exam Template - 1
An example normal physical exam
Normal Physical Exam Template - 2
Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact.
Normal Physical Exam Template - 3
Normal physical exam template. Well developed, well nourished, in no acute distress.
Normal Physical Exam Template - 4
Normal physical exam template. Normocephalic. Negative lesions, negative masses.
Normal Physical Exam Template - 5
Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress.
Normal Physical Exam Template - 6
Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.
Normal Physical Exam Template - 7
Most commonly used phrases in physical exam.
Normal ROS Template
Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.
Normal ROS Template - 1
There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing.
Normal ROS Template - 2
Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.
Normal ROS Template - 3
Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.
Normal ROS Template - 4
Negative for any nausea, vomiting, fevers, chills, or weight loss.
Normal ROS Template - 5
Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.
Ortho Office Visit
The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.
Post Dilation Instructions
Sample post dilation patient instructions.
Premature retina and vitreous
Small office note on premature retina and vitreous.
Right Hand Laceration
Right hand laceration x3, repaired.
Shoulder Contusion
Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.
Status Post T&A
Underwent tonsillectomy and adenoidectomy two weeks ago.
Status Post Tympanoplasty
The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago.
Tachypnea
Quick note on tachypnea.
Telemetry Monitoring
The patient was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.