CHIEF COMPLAINT: Skin rashes, GU: NO dysuria, frequency,

lesions hematuria (also includes vaginal

bleeding, discharge, foul smell, penile
discharge, penile bleeding, etc)
HPI: Pt is a 28 years old, female,
MSK: No leg edema. No midline
(M/F) presenting knee and ankle
spinal tenderness.
pain. The patient twisted her ankle
and fell on the right side, ____ her
right knee and elbow that happened
few hours ago. The patient cannot Neuro: headaches, dizziness, seizures,
limp and partially in pain. The patient LOC, tingling
rates her knee pain at 9/10 while her Skin: NO rashes, erythema, nevi,
ankle pain is at 12/10. The patient lacerations
take vigon for pain.
Psych: NO depression, anxiety,
suicidal ideation, homicidal ideation
ROS: (+/-) for each symptom
Constitutional: NO Fever, chills, PE: (+/-) OR written out. I’m going to
weight gain, weight loss, fatigue give a very general one simply
Eyes: NO Erythema, dry, tearing, because there is so much you can put
discharge, blurred vision, double under here.
vision *Always check vital signs stable (if
HENT: NO Hearing loss, Ear pain, ear stable) or that they were reviewed!
itching, rhinorrhea, congestion, sore Constitutional: Appears
throat, hoarseness, epistaxis well/cachectic/malnourished, Acute
CV: NO palpitation distress/no acute distress, sitting
comfortably, converses normally.
Smells of tobacco/smells fruity.
Resp: NO shortness of breath, cough,
Describe their appearance.
wheezing, sputum production
HENT: Atraumatic, normocephalic
GI: NO Abdominal pain, nausea,
head. External ears: pinna are
vomiting, diarrhea, melena,
symmetric without deformities. Canal
hematochezia, difficulty swallowing
is clear without cerumen or
excoriations. Tympanic membranes MSK: FROM in extremities where
are translucent without erythema, checked. No leg edema. No midline
exudate, or perforation. Cone of light spinal tenderness.
present. Nares patent. No turbinate
Neuro: A&Ox3. CN II-XII grossly
swelling. No nasal discharge, septal
intact. DTR’s 2+/4 to brachioradialis,
deviations, septal perforations. Uvula
biceps, triceps, patellar, and Achilles.
midline. Tonsils are not
Strength 5/5 in upper and lower
erythematous, edematous, no
extremities bilaterally. Sensation
exudates. Posterior oropharynx is
intact grossly.
clear. Mucous membranes are moist.
No lesions present. (there are more you can put here but
I won’t get any more detailed).
Eyes: PERRLA. EOMI. No conjunctival
pallor. Red reflex present. No
strabismus. (There is a full Hospital Course:
fundoscopic exam that can be
performed here that is typically only If you are in the ER, this is where you
required if the complaint warrants it). would timestamp and keep track of
what happened while they were in
Neck: No LAD. Supple. No nuchal the ER, what labs were ordered, if
rigidity. ROM appropriate. Thyroid anything urgent came back, checkups
not enlarged, soft, non-tender. on the patient, and who you talked to
CV: Heart is RRR. No murmurs, rubs, about the patient.
or gallops. Normal S1 & S2. Pulses
equal and intact bilaterally to upper
and lower extremities. Cap refill <2 EKG’s and procedures tend to go in
seconds. this area as well.

Lungs: CTA bilaterally. No wheezes,

rhonchi, or rales. No upper airway Assessment:
sounds.
Choice 1: MDM, Dx, & deposition
GI: Abdomen soft, non-distended,
In certain branches of medicine, you
non-tender. Bowel sounds normal in
will have an MDM or “medical
all 4 quadrants. Normal tympany.
decision making”. This is a paragraph
or two of what the patient presented
with, what physical exam findings Deposition: admit, discharge,
were pertinent, what labs you deceased, etc.
ordered and your reasoning why. You
Additional:
are discussing what you ruled out and
what you ruled in, and what you were This is where you would put follow
concerned about. You then discuss up, write any discharge instructions
any important lab/imaging findings for your patient, and billing. It is not
here and you reason to admit, send usually part of the note and is in a
to observation, or discharge. separate tab of your program with
the billing.

Dx: You would then list diagnoses.

Deposition: Admit, discharge,

observation, or deceased

Choice 2: Assessment and Plan

Assessment: You would list your

diagnoses or differential diagnoses if
you are unsure.

Plan: You would then discuss the plan

in either a bullet format or paragraph
format. You can do it grouped with
the specific diagnosis or group of
related diagnoses, or do it
separately.
 GI: NO Abdominal pain, nausea,
vomiting, diarrhea, melena,
hematochezia, difficulty swallowing
CHIEF COMPLAINT: Neck Pain
GU: NO dysuria, frequency,
hematuria (also includes vaginal
HPI: Pt is a 28 years old, male, (M/F) bleeding, discharge, foul smell, penile
presenting knee and ankle pain. The discharge, penile bleeding, etc)
patient twisted her ankle and fell on MSK: No leg edema. No midline
the right side, ____ her right knee spinal tenderness.
and elbow that happened few hours
ago. The patient cannot limp and
partially in pain. The patient rates her Neuro: headaches, dizziness, seizures,
knee pain at 9/10 while her ankle LOC, tingling
pain is at 12/10. The patient take
vigon for pain. Skin: NO rashes, erythema, nevi,
lacerations
Psych: NO depression, anxiety,
ROS: (+/-) for each symptom suicidal ideation, homicidal ideation
Constitutional: NO Fever, chills,
weight gain, weight loss, fatigue
PE: (+/-) OR written out. I’m going to
Eyes: NO Erythema, dry, tearing, give a very general one simply
discharge, blurred vision, double because there is so much you can put
vision under here.
HENT: NO Hearing loss, Ear pain, ear *Always check vital signs stable (if
itching, rhinorrhea, congestion, sore stable) or that they were reviewed!
throat, hoarseness, epistaxis
Constitutional: Appears
CV: NO palpitation well/cachectic/malnourished, Acute
distress/no acute distress, sitting
Resp: NO shortness of breath, cough, comfortably, converses normally.
wheezing, sputum production Smells of tobacco/smells fruity.
Describe their appearance.
HENT: Atraumatic, normocephalic GI: Abdomen soft, non-distended,
head. External ears: pinna are non-tender. Bowel sounds normal in
symmetric without deformities. Canal all 4 quadrants. Normal tympany.
is clear without cerumen or
MSK: FROM in extremities where
excoriations. Tympanic membranes
checked. No leg edema. No midline
are translucent without erythema,
spinal tenderness.
exudate, or perforation. Cone of light
present. Nares patent. No turbinate Neuro: A&Ox3. CN II-XII grossly
swelling. No nasal discharge, septal intact. DTR’s 2+/4 to brachioradialis,
deviations, septal perforations. Uvula biceps, triceps, patellar, and Achilles.
midline. Tonsils are not Strength 5/5 in upper and lower
erythematous, edematous, no extremities bilaterally. Sensation
exudates. Posterior oropharynx is intact grossly.
clear. Mucous membranes are moist. (there are more you can put here but
No lesions present. I won’t get any more detailed).
Eyes: PERRLA. EOMI. No conjunctival
pallor. Red reflex present. No
strabismus. (There is a full Hospital Course:
fundoscopic exam that can be If you are in the ER, this is where you
performed here that is typically only would timestamp and keep track of
required if the complaint warrants it). what happened while they were in
Neck: No LAD. Supple. No nuchal the ER, what labs were ordered, if
rigidity. ROM appropriate. Thyroid anything urgent came back, checkups
not enlarged, soft, non-tender. on the patient, and who you talked to
about the patient.
CV: Heart is RRR. No murmurs, rubs,
or gallops. Normal S1 & S2. Pulses
equal and intact bilaterally to upper EKG’s and procedures tend to go in
and lower extremities. Cap refill <2 this area as well.
seconds.
Lungs: CTA bilaterally. No wheezes,
Assessment:
rhonchi, or rales. No upper airway
sounds. Choice 1: MDM, Dx, & deposition
In certain branches of medicine, you related diagnoses, or do it
will have an MDM or “medical separately.
decision making”. This is a paragraph
or two of what the patient presented
with, what physical exam findings Deposition: admit, discharge,
were pertinent, what labs you deceased, etc.
ordered and your reasoning why. You Additional:
are discussing what you ruled out and
what you ruled in, and what you were This is where you would put follow
concerned about. You then discuss up, write any discharge instructions
any important lab/imaging findings for your patient, and billing. It is not
here and you reason to admit, send
to observation, or discharge.

Dx: You would then list diagnoses.

Deposition: Admit, discharge,

observation, or deceased

Choice 2: Assessment and Plan

Assessment: You would list your

diagnoses or differential diagnoses if
you are unsure.

Plan: You would then discuss the plan

in either a bullet format or paragraph
format. You can do it grouped with
the specific diagnosis or group of
 Genitourinary:
Neurologic:
Psychiatric:

Physical Exam (PE):

Chief complaint (CC):

Skin Lesions, lower back rash Objective:

History of Present Illness (HPI): Assessment:

The patient is a 65 years old, female, Dermatits: 3 weeks erythematous

presenting skin lesions and lower rash, which worsen in the morning.
back rash for 3 weeks. The patient Suspect fungal vs dermatitis occurring
noted that it occurred after going to after patient visited the beach,
the beach. Itching is worse in the however it is unclear if this is related
morning. The patient denies having to the cause of the rash. Prescribed
similar rashes in the past and notes with Triacinolone x 1 month. Hot
that the itchiness has worsened in compress and cortisone cream
the last week. She has been applying provide relief. If not improved,
cortisone cream and using hot advised to consult with Dr. Yu DERM
compress with relief. Dr. Yu is her at 6 mos or consider topical steroid.
dermatologist and the patient has her Seborrheic Keratoses: 2 Aks on
next visit in 6months. forehead treated today in-office with
Review of Systems (ROS): liquid nitrogen

Constitutional: Discussed:
ENT:
Apply triamcinolone to your lower
Cardiovascular:
back rash for 1 month and also apply
Gastrointertinal:
Skin: Several small, 3 inches x 2 sunscreen. Follow-up with your
inches erythematous circular, raised dermatologist or our office if your
spots in lower back region rash does not clear after using topical
2 light tan, waxy, scaly, and slightly antifungal cream.
raised lesions consistent with SKs Plan:
2 rough, scaly patches on forehead
consistent with AKs
Area was cleansed with ethanol. 2 Musculoskeletal: no back pain, no
Aks treated today in-office with liquid neck pain, no extremity pain, no
nitrogen. decreased ROM
Skin: no pruritus, no rashes, no
lesions, no abrasions, no
Chief complaint (CC): discoloration

Diarrhea
Physical Exam (PE):
History of Present Illness (HPI):
General: awake, alert, and oriented,
Patient is a 27-year-old male mild distress
presenting stomach pain and
diarrhea that started 3 days ago. Pt Skin: warm, dry, and intact without
has had nausea and vomited 2x. Pt rashes or lesions
describes a watery but not much Head: normocephalic, atraumatic
mucus stool. Pt denies blood in his
Eyes: pupils are equal, round, and
stool. Pt reports having abdominal
reactive to light (PERRLA), clear
cramps that gets better after going to
conjunctiva without hemorrhage or
the bathroom. Pt rates his pain at
exudates, no scleral icterus
6/10. Pt had taken pepto Bismol that
gave him slight relief of cramps and ENT: hearing intact, moist mucous
diarrhea. Pt loss his appetite. Pt membranes, nares patent bilaterally
history of travelling might cause his
Neck: supple, no JVD, normal cervical
sickness but no known cause.
lymphadenopathy
Review of systems (ROS):
Cardiovascular: normal rate and
HEENT: loss of appetite rhythm, no murmurs, rubs or gallops,
Cardiovascular: no chest pain, no normal peripheral perfusion
SOB, no palpitations, no orthopnea
Neuro: no numbness, no weakness, Pulmonary: Lungs CTA, no wheezes,
no dizziness, no lighheadedness, no rales or rhonchi, no respiratory
LOC, +HA distress
Respiratory: no cough Gastrointestinal: no epigastric
Gastrointertinal: +nausea, +vomiting, tenderness, normal bowel sounds, no
+diarrhea, + abd pain, no contipation
organomegaly
Musculoskeletal: upper and lower
extremities are atraumatic without
Diagnosis:
swelling or erythema, Full ROM
Migraine with aura
Neurological: normal gait, cranial
nerves intact, normal neuro exam Plan/Procedure:

Psychological: appropriate mood and -Pt given 1L of oxygen via nasal

affect, good judgement canula
-Pt given dose of Rizatriptan
Assessment: -Sx improved with this treatment, pt
Patient is a19-year-old female with will be discharged
PMHx of migraines presenting -Pt given Rx for Rizatriptan
-Discussed migrained diary with pt
evaluation for migraines with aura
-Recommend pt keep track of
onset 10 hours ago that is not
migraine episode and Sx to assess
responding to Imitrex or Tylenol. Pt possible triggers
usually has migraines around -FF for PCP or to return to clinic
menstrual cycle and throughout -Pt understand and agress with
month lasting a few hours. This treatment plan
migraine is longer with 10 hours Sx.
Sx of photophobia, nausea, blurry
vision are normal for patient’s
migraines. Vital signs WNL, RR and BP
slightly elevated, probably due to
pain. On exam, pt in mild distress,
otherwise normal PEx. Initial concern
for stroke or aneurysm. Given PMHx,
normal neuro exam, current Sx,
suspect typical migraine with aura
not responding to normal meds. Pt
had CT 5 years ago for migraine that
was normal, so no need to repeat
study today. Pt given dose of
rizatriptan and 1L O2 via nasa canula.
If Sx improve, will discharge home
with Rx for Rizatriptan.
 HEENT: no vision changes, no
erythema, no sore throat, no
rhinoorrhea

Cardiovascular: no chest pain, no

SOB, no palpitations, no orthopnea
Respiratory: no cough
Gastrointertinal: +nausea,
Chief complaint (CC): +suprapubic abdominal pain, no
Left Plank Pain vomiting or bloody stools
Musculoskeletal: no back pain, no
History of Present Illness (HPI): neck pain, no extremity pain, no
Pt is a 61 year-old male with Hx of decreased ROM
HTN and CAD presenting evaluation Skin: no pruritus, no rashes, no
for chest pain. Pt reports symptoms lesions, no abrasions, no
of nausea and vomited once. Pt discoloration
noted a sharp, substernal, squeezing
chest pain that radiates to his left Physical Exam (PE):
arm up to his jaw. Pt rated his pain at
9/10. Pt has not improved with General: awake, alert, and oriented,
drinking water. Pt reports nothing no acute distress
made it better or worse at home. Pt Skin: warm, dry, and intact without
called EMS, they gave him some
rashes or lesions
medicine that he doesn’t know of and
seemed to help a little bit, but now Head: normocephalic, atraumatic
his chest pain is back. Pt also noted
Eyes: pupils are equal, round, and
that he has never had similar pain
before. reactive to light (PERRLA), clear
conjunctiva without hemorrhage or
Cbc, Cmp, Ua, Ct of abdomen and exudates, no scleral icterus
pelvis ENT: hearing intact, moist mucous
Zphran and morphine for nausea membranes, nares patent bilaterally
Unremarkable but left cva tenderness Neck: supple, no JVD,

Review of systems (ROS):

Cardiovascular: normal rate and Diagnosis:
rhythm, no murmurs, rubs or gallops,
Kidney Stone
normal peripheral perfusion
Plan/Procedure:
Pulmonary: Lungs CTA, no wheezes,
rales or rhonchi, no respiratory -Pt given Rx for IV Zofran and Norco
distress for nausea and pain.

Gastrointestinal: +left cva -Pt is discharge

tenderness
Musculoskeletal: upper and lower
extremities are atraumatic without
swelling or erythema, Full ROM
Neurological: normal gait, cranial
nerves intact,
Psychological: appropriate mood and
affect, good judgement
Assessment:
The PT is a 35-year-old female with
Hx of HTN and frequent UTIs
presenting evaluation for severe left
flank pain that radiates to the left
suprapubic region. Associated
symptom include nausea. On initial
exam, patient exhibits left CVA
tenderness.
Initial differential diagnosis include:
Pyloneprhitis, hydroneprhoisis,
nephrolithiasis, gastritis, uti,
dehydration, electrolyte
abnormalities.
The patient was given IV Zofran and
Norco for nausea and pain.
 HEENT: no vision changes, no
erythema, no sore throat, no
rhinoorrhea
Cardiovascular: no chest pain, no
SOB, no palpitations, no orthopnea
Chief complaint (CC): Respiratory: no cough
Cough
Gastrointertinal: +nausea,
History of Present Illness (HPI): +suprapubic abdominal pain, no
Pt is a 73-year-old female with Hx of vomiting or bloody stools
COPD presenting c/o 1 week of a Musculoskeletal: no back pain, no
productive cough with yellow-white neck pain, no extremity pain, no
sputum. Pt noted her cough to be decreased ROM
constant and interfering with her Skin: no pruritus, no rashes, no
daily activities and sleep. Because of lesions, no abrasions, no
this, Pt has been fatigued more than discoloration
usual. The Pt recently had pneumonia
which improved on antibiotics, but Physical Exam (PE):
has had 3 other bouts of pneumonia
this year. Deep breathing worsen her General: awake, alert, and oriented,
cough and causes pleuritic pain. no acute distress
Cough syrup has slightly improved
Skin: warm, dry, and intact without
her symptoms. Other associated
rashes or lesions
symptoms include malaise and R
sided rib pain which presented after Head: normocephalic, atraumatic
her coughing started. Rib pain is
pleuritic and rated 7/10. This Eyes: pupils are equal, round, and
improves with manual compression reactive to light (PERRLA), clear
of the area. Of note, Pt has both a conjunctiva without hemorrhage or
rescue inhaler and long-acting inhaler exudates, no scleral icterus
at home. Pt has needed her rescue ENT: hearing intact, moist mucous
inhaler more this past week,
membranes, nares patent bilaterally
reporting using it upwards of 6x or
more a day. Neck: supple, no JVD,

Review of systems (ROS):

Cardiovascular: normal rate and Based on the physical and imaging
rhythm, no murmurs, rubs or gallops, result, the patient is diagnosed with
normal peripheral perfusion kidney stone.
Pulmonary: Lungs CTA, no wheezes, Diagnosis:
rales or rhonchi, no respiratory
Kidney Stone
distress
Plan/Procedure:
Gastrointestinal:
-Pt given Rx for IV Zofran and Norco
Musculoskeletal: upper and lower
for nausea and pain.
extremities are atraumatic without
swelling or erythema, Full ROM -Pt is discharge

Neurological: normal gait, cranial

nerves intact,
Psychological: appropriate mood and
affect, good judgement
Assessment:
The PT is a 35-year-old female with
Hx of HTN and frequent UTIs
presenting evaluation for severe left
flank pain that radiates to the left
suprapubic region. Associated
symptom include nausea. On initial
exam, patient exhibits left CVA
tenderness.
Initial differential diagnosis include:
Pyloneprhitis, hydroneprhoisis,
nephrolithiasis, gastritis, uti,
dehydration, electrolyte
abnormalities.
The patient was given IV Zofran and
Norco for nausea and pain.