Patient Chart

Patient ID: VT Day 5-1

Progress Notes
Subjective:

Chief Complaint:

Headache

History of Present Illness:

35-year-old Nikki Lomax presented herself to the clinic with the chief complaint of a
headache.

The patient said it started three days ago when she was lifting weights and running on
the treadmill. After that, she blacked out. The patient admits she has not been in the
gym for a long time.

The patient said the pain was at the back of her head.

The patient said the headache was there all the time.

The patient described the headache as annoying and quite strong.

The patient said that bending over worsened the pain, like putting her boots on.

The patient took Panadol and Neurofen, but they did not help much, and the patient
also took time off work.

The patient said the headache was affecting her daily life. She had to cancel her dinner
last week and she had to stop going to the gym.

The patient claimed vomiting.

The patient denied having a cough, cold, fever, rash, recent infection, vision
problems. Witnesses say there is no jerking of the limbs when she passed out.
Past History:

Medical History:

Surgical History:

Family History:

Social History:

Bank Manager
No alcohol

Smoking History:

Ex-smoker. The patient quit smoking last year.

Allergies:

Current Medications:

Panadol, Neurofen, Marvelon

Review of Systems:
Constitutional: -cold, fever
Head:

Neck:

Eyes: - vision problems

Ears:

Nose:

Mouth:

Throat:

Cardiovascular:

Respiratory: - cough,

Gastrointestinal: + vomiting
 Genitourinary:

Musculoskeletal:

Integumentary (skin and/or breast): - rash

Neurological: - jerking of the limbs

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:- recent infection

Objective:

Vital Signs:
Height: Weight: BMI Interp: Systolic 160 Diastolic 90

Pulse (beats/min):

Physical Examination:

Constitutional:

EENT:

NECK: stiff and tender on flexion

Respiratory:

CARDIO:

Lungs:

Chest/Breast:

Heart:

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:
Musculoskeletal

 Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES:

Neurologic/Psychiatric: Fundoscopy: NAD Neurology nil focal

 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:
 Hemoglobin: 8.7 g/dl

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:
  To talk to a specialist
 To organize transport to take the patient to a hospital
 To request scan of the head of the patient

Patient Instructions/Follow Up:

 Educated the patient about her situation. Informed the patient about stress
making headaches worse, but it just wouldn’t cause headaches to cause
something like her presented symptoms. Generally, migraines tend to present
as one-sided headaches.
 Informed the patient that she does not have a migraine but might have a small
bleeding in the back of her brain. Given the situation, she blacked out three
days ago after having a headache.
 Suggested the patient not take stronger painkillers.

 To follow up with and present results of the CAT scan

Patient Chart

Patient ID: VT day 5-2

Progress Notes
Subjective:

Chief Complaint:

Difficulty of breathing, shortness of breath

History of Present Illness:

A 25-year-old female patient came to the clinic with the chief complaint of difficulty
breathing and shortness of breath.

The patient said it started last night.

The patient said the right side of her lungs hurt when she inhales.

The patient described the pain as a sharp pain every time she breathed.

The patient admits to having headaches once in a while and tingling in her hands.
The patient denies having a cough, sore throat, fever, congestion, belly pain,
migraines, nausea, leg pain, or swelling.

Past History:

Medical History:

Anxiety- not treated

Surgical History:

No surgical history

Family History:

Blood clot- Dad

Social History:

Left home at the age of 18, living on her own since then.

Smoking History:

Smoker- smokes a pack and a half per day

Allergies:

Current Medications:

Imitrex
Birth control pills

Review of Systems:

Constitutional: - fever
Head:

Neck:

Eyes:

Ears:

Nose:

Mouth:

Throat: - sore throat

Cardiovascular:
 Respiratory: -cough

Gastrointestinal: - belly pain, congestion, nausea

Genitourinary:

Musculoskeletal: - leg pain, leg swelling

Integumentary (skin and/or breast):

Neurological: + headaches, tingling of hands

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Constitutional:

EENT:

NECK:

Respiratory:

CARDIO:

Lungs: slightly diminished sounds right lung base

Chest/Breast:

Heart: tachycardia- 110

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic: - Homan’s sign

Musculoskeletal
  Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:
Assessment & Plan:
Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

 To request for a CAT scan with PE protocol

  To request for CBC BMP
 To enroll patient in Breathing Treatment

Patient Instructions/Follow Up:

 Informed patient it might take 2 hours for the result to come in



Patient Chart

Patient ID: VT Day 5-3

Progress Notes
Subjective:

Chief Complaint:

Chest Pain

History of Present Illness:

A male patient came to the clinic with a chief complaint of chest pain.

The patient said it started a week ago when they were moving into their new home
while he was lifting boxes.

The patient said the pain was on the right side of his chest. Sometimes it goes right
through his back.

The patient described the pain as like a knife sticking to his chest.

The patient said the pain worsened when he was lifting boxes.

The patient said taking Ibuprofen and taking a hot shower usually eases the pain.

The patient described the pain as 3/10 to 4/10 on the pain scale. The patient mentioned
it was interfering with his daily life.

The patient denies having night sweats, shortness of breath, heart flutter, or trauma.
Past History:

Medical History:

Heartburn sometimes

Surgical History:

No surgical history

Family History:

Dad died of a heart attack when he was 60 years old

Social History:

No siblings
Smoked marijuana when he was in high school
Works as a roofer
Right handed
Alcohol- drink 6 packs occasionally over the weekend

Smoking History:

Non- smoker

Allergies:

No allergies

Current Medications:

Ibuprofen

Review of Systems:
Constitutional: - night sweats

Head:

Neck:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Cardiovascular: -heart flutter, trauma

Respiratory: - shortness of breath

 Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary (skin and/or breast):

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Constitutional:

EENT:

NECK:

Respiratory:

CARDIO: A- unremarkable

Lungs: A- unremarkable

Chest/Breast: P- pain on the right side

Heart:

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:

Musculoskeletal
  Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:
Assessment & Plan:
Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

 Performed Osteopathic Manipulation Treatment on the patient

  To order request for EKG
 To check cholesterol levels

Patient Instructions/Follow Up:

 Informed the patient that the pain he is suffering from is likely a pain
associated with the musculoskeletal system, specifically the ribs, rather than
the heart.
 educated the patient about osteopathic manipulative treatment being a
treatment of the body as a whole. It is a series of hands-on techniques to treat
pain or restriction of range of motion and can be quite helpful with the
patient’s condition. Usually, the pain stays afterwards because the muscle is
sore.
 advised the patient to take Ibuprofen and take hot showers if he still needed
them. In case the patient feels the sharp pain again, he is advised to call the
office and take on the treatment again.
 Follow up in a week or two.

Patient Chart

Patient ID: VT Day 5-4

Progress Notes
Subjective:

Chief Complaint:

Weakness, fatigue, dizziness, light headed

History of Present Illness:

A male patient came to the clinic with a chief complaint of weakness, fatigue,
dizziness, and lightheadedness.

The patient stated it all started a few days ago and developed shortness of breath
yesterday.

The patient said he cannot rest and can’t lay down because he doesn’t seem to have the
strength to breathe.

The patient claims to have tightness in the chest and some aches in the legs.
The patient denies having a fever, visual problems, a runny nose, a sore throat, belly
pain, back pain, urinary symptoms, a rash, difficulty swallowing, or bowel changes.

Past History:

Medical History:

Thalassemia- the patient had transfusions.

Surgical History:

Family History:

Dad- Thalassemia, diabetes, hypertension- Italian Background

Social History:

Smoking History:

Allergies:

Current Medications:

Review of Systems:
Constitutional: - fever

Head:

Neck: - visual problems

Eyes:

Ears:

Nose: -runny nose

Mouth:
 Throat: -sore throat

Cardiovascular:

Respiratory: + tightness in the lungs

Gastrointestinal: - belly pain, bowel changes, difficulty swallowing

Genitourinary: - urinary symptoms

Musculoskeletal: + some ache in the leg

- back pain

Integumentary (skin and/or breast): -rash

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Constitutional:

EENT: Conjunctival power

NECK:

Respiratory:

CARDIO: Borderline Jugular Vein Distention

Lungs: fine rales at the bases

Chest/Breast:

Heart: Tachycardia 112 S3 gallops

Gastrointestinal/ABDOMEN: slight hyperactive bowel sounds, splenomegaly 3 finger breaths below left costal margin
Genitourinary:

Lymphatic:

Musculoskeletal

 Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES:
Trace pedal edema bilaterally
Pale nailbeds

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate: 110
Rhythm: sinus tachycardia
Axis: normal
Ectopy: no ectopy
Conduction: normal
P wave: small p waves 2 3 AVF
Q wave: non specific q waves
ST-T wave changes: non specific stt changes
Comparison: no EKG comparison
Impression: sinus tachycardia
Image:
 Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

2
 3

Plan Notes:

 To request for CBC, liver function test, EKG- done with result, portable chest
X-ray, troponin, BMP, urinalysis, type and crossmatch packed red cell
 To administer four Morphine and four Zofran
 To contact hospital for admission

Patient Instructions/Follow Up:

 Informed the patient the nurse will start an IV and the patient might undergo
transfusion
 Informed the patient the doctor will get back to him once the results are out

Patient Chart

Patient ID:

Progress Notes
Subjective:

Chief Complaint:

History of Present Illness:

Past History:

Medical History:

Surgical History:

Family History:

Social History:
 Smoking History:

Allergies:

Current Medications:

Review of Systems:
Constitutional:

Head:

Neck:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary (skin and/or breast):

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:
 Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Constitutional:

EENT:

NECK:

Respiratory:

CARDIO:

Lungs:

Chest/Breast:

Heart:

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:

Musculoskeletal

 Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
  Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description
 Assessment Notes Assessment
Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

Patient Instructions/Follow Up: