Patient Chart

Patient ID: Pre-vignettes 1

Progress Notes
Subjective:

Chief Complaint:

headache

History of Present Illness:

This 25-year-old female patient came into the clinic with a CC of headache.

O: She stated that it started this morning as soon as she opened her eyes.

L: It is located all over her head but it is most felt in the frontal area.

D: It has not disappeared since it started.

C:

A: It worsens with strong odors, sudden movements and bright lights.

R asked her boss for a half day off to rest out the pain.

T : It remains the same kind of pain.

S : It gets in the way of her work. She was not able to finish her tasks at work
and asked her boss for a half day off to rest out the pain.

+ She feels dizzy, lightheaded, and a little blurring of vision. She also feels a
little weakness on her left arm and leg. She feels nauseated.

(-) She does not feel any vision loss, shaking of any body parts, or slurring of
speech. She denies vomiting.
Perception: She is worried that this could be some sort of brain tumor. Hence,
the consultation.

Past History:

Medical History:

Asthma

Surgical History:

Left eye brow sutured due to laceration, 2019

Family History:

Mom – history of migraine in her 40’s

Dad – hypertension
Grandpa – hypertension, father’s side

Social History:

Bank manager
Traveled to Japan for 1 week; arrived back two days ago
Attended a birthday party last night until midnight; drank 1 case of red horse
Goes to the gym

Smoking History:

Allergies:

Crabs – itchy skin and rashes

Current Medications:

Panadol and Nurofen

Pill- Marvelon
 Review of Systems:

Constitutional:

Head:

Neck:

Eyes: + a little blurring of vision, (-) vision loss

, (-) vision loss

Ears:

Nose:

Mouth: -slurring of speech

Throat:

Cardiovascular: + lightheaded

Respiratory:

Gastrointestinal :+ nausea,(-) vomiting

,(-) vomiting

Genitourinary:

Musculoskeletal: + a little weakness on her left arm and leg, (-) shaking of any body parts

(-) shaking of any body parts

Integumentary (skin and/or breast):

Neurological: + dizziness, lightheaded

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:
 Vital Signs:

Height: Weight: BMI Interp: Systolic: 90 Diastolic: 60

Pulse (beats/min):

Physical Examination:

Constitutional:
Appears agigated

EENT: Anisocoria

NECK: tenderness on the neck; limited movement of neck;

Respiratory: slightly diminished breath sounds on the right lung base

CARDIO: Tachycardia 130

Lungs: slightly diminished breath sounds on the right lung base

Chest/Breast:

Heart: Tachycardia 130

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic: negative Homan’s sign

Musculoskeletal

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

SKIN:

EXTREMITIES:

Weakness to the left arm and leg negative Homan’s sign

Neurologic/Psychiatric:

 Cranial Nerves- Cranial nerves 2-12 intact

 Sensory and Motor Exams - Weakness to the left arm and leg
 Reflex testing- Babinski reflex (-), DTR, +2
 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 order CT scan of the brain

 To admit to neuro ward
 To start IVF PNSS 1L @ 120cc/hr


 To order CT scan of the brain

 To admit to neuro ward
 To start IVF PNSS 1L @ 120cc/hr
 

Patient Instructions/Follow Up:

 Informed patient the cause of headache is still unknown but it is more likely
brain-related.
 Advised to avoid strenuous activities and get plenty of rest.

Patient Chart

Patient ID: Pre-vignettes 2

Progress Notes
Subjective:

Chief Complaint:

Loose stools

History of Present Illness:

This 6 year old male patient was brought to the clinic with a CC of loose stools.

O The mother stated his son started having loose stools last night.

D He has been passing stools since for 8 times since it started.  Where is
the length of time here?

C His stool is watery and it contains some indigested food. He has been
passing stools since for 8 times since it started.

A
R He was given Hydrite but it had no sooner flushed as soon as it is taken in.
She did not let her son go to school today and let her son have some rest.

T The passing of stool became shorter in intervals.

S She noticed her son gets weaker and weaker. She keeps sleeping and is
very hard to wake up. She did not let her son go to school today and let her
son have some rest.

+ She thinks he has a fever because his skin is warmth to touch. She was told
by his son that he feels lightheaded earlier. He keeps complaining of being
thirsty all the time. He also complains of stomach cramps. She noticed her son
gets weaker and weaker. She keeps sleeping and is very hard to wake up.

(-) She denies seeing any blood in her son’s stool. He does not feel nauseated
nor did he vomit.

Perception:

Past History:

Medical History:

No medical condition

Surgical History:

Family History:

Mom – diabetes
Dad, Paternal grandpa – asthma

Social History:
Eats street foods at school
Went to a swimming pool yesterday

Smoking History:

Allergies:

NKA

Current Medications:

Ascorbic acid

Review of Systems:

Constitutional: + gets weaker and weaker, keeps sleeping, very hard to wake him
up.

Head:

Neck: - neck pain

Eyes: - blurry or double vision

Ears:

Nose:

Mouth:

Throat:

Cardiovascular:

Respiratory: - productive cough

Gastrointestinal: (-) blood in the stool, nauseated, vomiting

Genitourinary:

Musculoskeletal: - neck pain

Integumentary (skin and/or breast): + skin is warmth to touch

 feels lightheaded earlier, (-) headache, seizures
Neurological: +
(-) headache, seizures
Psychiatric:

Endocrine: + being thirsty all the time

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min): HR: 100 bpm

Physical Examination:

Constitutional: Temperature: 38.3*C

EENT: + Dry mouth and mucous membrane

NECK:

Respiratory: RR: 20 cpm

CARDIO:

Lungs: Clear breath sounds

Chest/Breast:

Heart: HR: 100 bpm

Gastrointestinal/ABDOMEN: Significant borborygmi, Mild diffuse abdominal tenderness

Genitourinary:

Lymphatic:
Musculoskeletal

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

SKIN: + Dry 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: CBC:elevated leukocytes

Increase hematocrit level
 CBC: elevated leukocytes
Increase hematocrit level

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 start bolus IVF of 2L fast drip
 To order CBC, hct, serum electrolytes, stool exam
 To admit patient to Pedia ICU

 To start bolus IVF of 2L fast drip

 To order CBC, hct, serum electrolytes, stool exam
 To admit patient to Pedia ICU


Patient Instructions/Follow Up:

 Informed SO that her son is possibly having acute gastroenteritis which is

acquired from poor food handling or ingestion of contaminated food or water.
 Informed SO that her son is having severe dehydration and needs to be
rehydrated as soon as possible.
 Educated to observe proper food handling.
 Informed SO that medication will be given as soon as the cause stool exam
result is in.

o all out, Sabog version!

Patient Chart

Patient ID:

Progress Notes
Subjective:

Chief Complaint:

Chest pain

History of Present Illness: This 55-year male patient came into the clinic with a CC of
chest pain.

His wife prompted to call 911 right away as soon as she noticed her husband feeling
in pain.

O It came out of nowhere while having intimate moments with his wife 2 hours earlier.
They were right in the middle of the moment when the chest pain happened. He never
felt this before.

L The pain is located in the middle of the chest but it goes to the left shoulder and
arm, neck, and jaw, and it goes through the opposite side of back.

D It has not disappeared since its onset.

C It feels a sharp kind of pain right in the center of the chest. It is very uncomfortable
like a squeezing uncomfortable pressure on his chest..

A It gets worse with movement and when doing exertion.

R He tried taking antacid thinking it was just a heartburn from over-exertion while
having ‘that’ moment but it did not relieve it.

T It appears to be getting worse over time.

S The pain scale is at 10/10. He tries not to move too much as it worsens the pain.
He just remains seated the whole time.

+ He also felt shortness of breath as if someone is sitting right on his chest. He also
felt lightheaded, and nauseated. He also sweat all throughout and his skin feels cold
and clammy

(-)

Perception:

Past History:

Medical History:

HTN and DM – diagnosed 2017 during annual PE at work – both prescribed with
unrecalled meds but he never complied

Surgical History:

Family History:

Mom – HTN
Maternal Grandma – HTN – died of stroke
2015 at 85

Social History:

Drinks alcohol 2-4 glasses every weekend

No street drugs
Loves beef steak
Does not do exercise
Manager in a construction firm
Smoking History:

Smokes a pack per day

Allergies:

Seafood - rashes

Current Medications:

Gaviscon

Review of Systems:
Constitutional:

+ appears in acute pain and distress

Head:

Neck:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Cardiovascular: + rapid and irregular heart beat

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary (skin and/or breast):

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:
 Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: 80 kg BMI Interp: Systolic: 110 Diastolic: 60

Pulse (beats/min):

Physical Examination:

Constitutional: + appears in acute pain and distress

EENT:

NECK:

Respiratory: O2 sat 90%; RR 25

CARDIO: 90 bpm rapid and irregular

Lungs:

Chest/Breast:

Heart: + rapid and irregular heart beat

90 bpm rapid and irregular

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:

Note prioritize plans according to importance.

 To hook to O2 support via nasal cannula at 5 lpm  3rd

 To administer Morphine Sulfate, warfarin and aspirin  2nd

 To start IVF PNSS 100 cc/hr  1st
 To admit to CCU
  To order EKG, CBC, Trop T
 To order echocardiogram and angiogram

Patient Instructions/Follow Up:

Explained the nature of the illness.

 Informed patient he is likely having a heart attack.

 Advised to be on complete bed rest without bathroom privileges