CodingMari
Networker
patient present with translator with complaint of burninf in center chest and sore throat.patient went to ER XXX and was given a good GI cocktail with good results. patient was then discharge on omeprazole xx but patient stated that didn't really help. patient prescribe xxx with refills in may xxx xxx no etoh /smoking + caffeine states she gets pain some discomfort for past coupl days with swallowing but no difficulty swallowing.
vs: temp xx
pulse xx
resp xxx
bp xxx
wt xx
gen: alert well nourished and well hydrated in no distress
heent: conjuctiva normal
auditory canals normal
right tympanic membrane is intact without fluid or edema
left tympanic membrane is intact without fuid or edema
nares without mocupurulent congestion bilaterally
oral exam without lesions posterior pharynx with mild erythema no tonsillar exudates no palatal petechiae
lungs: clear to auscultation without wheezing rhonci,or rales
cor: rrr with normal s1 s2 without murmur gallop or rub
abd: +epigastric ttp no guarding no rebound +BS through no guarding no rebound
dx pharyngitis likely viral GERD
MED: continue on protinc
refer to gi
I see EXAM =vitals, general, eyes, ENTM, NECK, LUNGS,CARD,ABD =EPF?
HPI=LOCATION,QUALITY,DURATION, MODIFYING FACTOR? 4=DETAIL?
PPT- ESTABLISH PROBLEM WORSENING =2
DATA=0
RISK=LOW RISK?
I would really appreciate some feed back
vs: temp xx
pulse xx
resp xxx
bp xxx
wt xx
gen: alert well nourished and well hydrated in no distress
heent: conjuctiva normal
auditory canals normal
right tympanic membrane is intact without fluid or edema
left tympanic membrane is intact without fuid or edema
nares without mocupurulent congestion bilaterally
oral exam without lesions posterior pharynx with mild erythema no tonsillar exudates no palatal petechiae
lungs: clear to auscultation without wheezing rhonci,or rales
cor: rrr with normal s1 s2 without murmur gallop or rub
abd: +epigastric ttp no guarding no rebound +BS through no guarding no rebound
dx pharyngitis likely viral GERD
MED: continue on protinc
refer to gi
I see EXAM =vitals, general, eyes, ENTM, NECK, LUNGS,CARD,ABD =EPF?
HPI=LOCATION,QUALITY,DURATION, MODIFYING FACTOR? 4=DETAIL?
PPT- ESTABLISH PROBLEM WORSENING =2
DATA=0
RISK=LOW RISK?
I would really appreciate some feed back