Shorthand

[text name="or    " default="sample text"][text name="variable_1" default="sample text"][textarea name="variable_1" default="sample text"][text name="variable_1" default="sample text"][textarea name="variable_1" default="sample text"][date name="variable_1" default="06-05-2024"][shorthand name="5210"]Each day I recommend you eat 5 servings of colored foods (fruits and vegetables), spend no more than 2 hours a day in front of a computer or TV screen (not including work), exercise for 1 hour a day, and avoid sugary drinks like sweetened sodas, teas, or juices.[/shorthand][shorthand name="17ohprogesterone"]Your level of 17 hydroxyprogesterone (one of your female hormones) was normal.[/shorthand][shorthand name="1stob"]Prenatal care initial info reviewed, such as safe medications, warning signs, avoidance of alcohol and tobacco, illicit drugs, safe foods, chemical avoidance, expected symptoms, prenatal care and transfer information for after 12 weeks, delivery options, prenatal lab testing, and vitamin use.[/shorthand][shorthand name="a1ccontrolled"]Your average blood sugar (A1C) is ____ % . A number less than 7% means that your diabetes is well controlled. Good job![/shorthand][shorthand name="a1ccontrolledAGS"]Your average blood sugar (A1C) is ____ % . A number less than 7.5% means that your diabetes is well controlled. Good job![/shorthand][shorthand name="a1cdiabetesdx"]Your average blood sugar (A1C) is ____ . A result of 6.5% or higher means that you meet the American Diabetes Association's criteria for adult diabetes (diabetes mellitus type 2).
Please make an appointment to discuss this result. I will also refer you to our diabetes educator. She develops weekly classes that teach valuable information about how to control your blood sugar and understand your diabetes better.[/shorthand][shorthand name="a1chigh"]Your average blood sugar (A1C) is higher than it should be. It is ___ %. It should be less than 7.5%.[/shorthand][shorthand name="a1chigher"]Your average blood sugar (A1C) is higher than it was last time. It rose from ____ % to ____ %.[/shorthand][shorthand name="a1clower"]Your average blood sugar (A1C) is lower than it was last time. It dropped from ___ % to ___ %. Good job![/shorthand][shorthand name="a1cnormal"]Your average blood sugar (A1C) is normal. You do not have diabetes.[/shorthand][shorthand name="a1csame"]Your average blood sugar (A1C) is the same as it was last time. Good job![/shorthand][shorthand name="aaanormal"]The ultrasound of your aorta (the large blood vessel that runs from your heart to your legs) was normal. You do not have an aortic aneurysm.[/shorthand][shorthand name="aafped"]Given AAFP handout from familydoctor.org[/shorthand][shorthand name="aaos"]Do AAOS exercises per handout(s) given to patient[/shorthand][shorthand name="abdxray"]The x-ray of your abdomen does not show any abnormalities.[/shorthand][shorthand name="abiexercise"]The blood circulation in your legs is normal after exercise.[/shorthand][shorthand name="abipositive"]Your leg circulation test (ankle brachial index) showed decreased blood flow in your legs. I want to get an ultrasound to look more closely at the blood circulation in your legs. I placed an order for this test.[/shorthand][shorthand name="abipositivemildmoderate"]Your leg circulation test (ankle brachial index) showed mildly / moderately decreased blood flow in your legs. Continue your current treatments to control your blood pressure and cholesterol. If you smoke, quit smoking.[/shorthand][shorthand name="abirest"]The blood circulation in your legs is normal at rest.[/shorthand][shorthand name="abisevere"]Your leg circulation test (ankle brachial index) showed severely decreased blood flow in your legs. I want to get an ultrasound to look more closely at the blood circulation in your legs. I placed an order for this test.[/shorthand][shorthand name="abx"]antibiotic[/shorthand][shorthand name="ace"]The ACE (angiotensin converting enzyme test) was normal. An elevated ACE level is seen in people who have sarcoidosis.[/shorthand][shorthand name="ACTasthmacontroltest"]ACT >19 = asthma well controlled
ACT 16-19 = asthma not well controlled
ACT <16 = asthma very poorly controlled[/shorthand][shorthand name="ad"]advance directive[/shorthand][shorthand name="adhdadult"]Adult ADHD Self-Report Scale: Inattention: ___ / 9, Hyperactivity: ___ / 9[/shorthand][shorthand name="adhdmedadvice"]Do not take your ADHD medicine with anything that has caffeine (coffee, sodas with caffeine, weight loss supplements).[/shorthand][shorthand name="adhdvanderbilt"]Please complete the Vanderbilt ADHD Diagnostic Parent Rating Scale. Ask two of your child's teachers to complete the Vanderbilt ADHD Diagnostic Teacher Rating Scale. Bring the completed questionnaires to your child's next appointment.[/shorthand][shorthand name="afp"]The alpha fetoprotein test (test for liver cancer) was normal.[/shorthand][shorthand name="age75"]Routine screening no longer indicated because patient age > 75[/shorthand][shorthand name="ahagdlns"]Patient has a 10 yr CVD risk of ___ %. AHA / ACC guidelines recommend low / moderate / high dose statin therapy.[/shorthand][shorthand name="alkphosnormal"]Your alkaline phosphatase (ALP) is normal. ALP is an enzyme found throughout the body, but it is mostly found in the liver, bones, kidneys, and digestive system. When the liver is damaged, ALP may leak into the bloodstream. High levels of ALP can indicate liver disease or bone disorders.[/shorthand][shorthand name="allergy"]I think you have mild allergies causing your stuffy nose. Try Flonase Allergy or Nasacort AQ steroid nose spray for your stuffy nose. Squirt 2 sprays up each nostril once a day. You can take Zyrtec or Claritin as needed for runny nose or postnasal drip.[/shorthand][shorthand name="allergyc"]Counseling on management of allergic rhinitis provided, including role of over-the-counter pills, tachyphylaxis, steroid nasal sprays with use and side effects, Neti pot use, and precautions re: ingredients, etc. [/shorthand][shorthand name="allergyskin"]Take Zyrtec 10 mg 1 pill once a day.
Take Benadryl Allergy 25 mg 1 pill every 4 hours as needed for severe swelling or itching.
Put hydrocortisone 1 % cream on the red itchy areas on your neck and left forearm as needed.
You can also try calamine lotion or Benadryl cream[/shorthand][shorthand name="alt"]Your liver tests are normal[/shorthand][shorthand name="alts"]alternatives[/shorthand][shorthand name="ami"]amitriptyline[/shorthand][shorthand name="ammonia"]The amount of ammonia in your body is normal. This means your liver is getting rid of ammonia toxins the way it should.[/shorthand][shorthand name="ana"]Your test for autoimmune arthritis (arthritis when your body attacks its own joints) was negative (normal).[/shorthand][shorthand name="anaabnormal"]Your test for autoimmune arthritis (arthritis when your body attacks its own joints) was positive (abnormal).[/shorthand][shorthand name="anca"]The autoimmune disease test called ANCA was negative (normal). The ANCA test can be positive in people who have vasculitis (inflammation of the blood vessels) or Crohn's disease and ulcerative colitis (inflammation of the lining of your intestine).[/shorthand][shorthand name="anemia"]Your complete blood count shows that you are anemic.
Your white blood cell count (infection fighters) and your platelets (blood clotting cells) were normal.[/shorthand][shorthand name="antibioticsbirthcontrol"]The antibiotic I gave you can make your birth control less effective.  I recommend you avoid intercourse while taking the antibiotic or use condoms.[/shorthand][shorthand name="appt"]appointment[/shorthand][shorthand name="asthmahx"]PATIENT HAS ASTHMA SXS
less than 2 days/wk, more than 2 days/week but not daily, daily, throughout day
NIGHTTIME AWAKENINGS
less than 2x/mon, 3-4x/mon, more than 1x/wk, 7x/wk
USES SABA INHALER
less than 2 days/wk, more than 2 days a week but not daily, daily, several times a day
SXS INTERFERE W NORMAL ACTIVITY
none, minor, some limitation, extremely limited[/shorthand][shorthand name="AUDITneg"]AUDIT-C score <4. Alcohol screening negative.[/shorthand][shorthand name="AUDITnegative"]AUDIT-C score = ___. Alcohol screening negative.[/shorthand][shorthand name="AUDITpositive"]AUDIT-C score >/= 4. Alcohol screening positive.[/shorthand][shorthand name="awvhpi"]Patient presents to the clinic today for Annual Wellness Visit and has the following concern(s):
1)
2)
3)[/shorthand][shorthand name="b12folic"]You have normal amounts of vitamin B12 and folic acid vitamin in your body.[/shorthand][shorthand name="b12high"]You have more vitamin B12 in your body than you need.[/shorthand][shorthand name="b12low"]You have less vitamin B12 in your body than you should.[/shorthand][shorthand name="backpain"]Take the anti-inflammatory medicine (naproxen, ibuprofen) as prescribed
Take the steroid pills (Prednisone) each morning with food.
Read the handouts I gave you and start the back stretches. Once your back pain starts to get better, start the back exercises.[/shorthand][shorthand name="backupabx"]Start taking the antibiotic I gave you if your symptoms do not start to feel better after 2-3 days or if your symptoms get worse.[/shorthand][shorthand name="bc"]birth control[/shorthand][shorthand name="bcc"]Birth control counseling provided, with discussion of barrier methods, hormonal methods including combination pills and progesterone only methods, implants patches, ring, and IUDs. Discussed the pros and cons, effectiveness, and side effects.[/shorthand][shorthand name="becb"]Patient given antibiotics for bacterial exacerbation of chronic bronchitis manifested by 2 of these 3 sxs:
change in sputum color,
increased volume of sputum,
increased shortness of breath[/shorthand][shorthand name="benzodependence"]Patient must take benzodiazepine medication on a daily basis to control anxiety so that he/she can maintain activities of daily living and independent activities of daily living.[/shorthand][shorthand name="bili"]Your bilirubin levels are normal.[/shorthand][shorthand name="bilihigh"]Your bilirubin test is high. This test measures how well your liver recycles old blood cells. I want to check this test again to confirm the first result. [/shorthand][shorthand name="bililow"]Your bilirubin levels are lower than they were last time.[/shorthand][shorthand name="bilipanel"]Your total, direct, and indirect bilirubin levels are normal.[/shorthand][shorthand name="biopsy"]Keep the bandage on the biopsy site for 24 hours. Do not shower for 24 hours. After that you may shower normally. Rinse the area of the biopsy with soapy water and pat it dry. Cover the biopsy site with a Band-Aid. Come back to the clinic in 7-10 days to have the stitches removed. Contact us if you have increased pain, bleeding, increased redness, or other concerns.[/shorthand][shorthand name="biopsyhpi"]Patient presents today for biopsy of a suspicious skin lesion noted on a prior exam.
Risks, benefits, and alternatives of the procedure were explained to the patient. Consent was signed. All questions were answered.[/shorthand][shorthand name="bl"]borderline[/shorthand][shorthand name="blister"]Each day rinse your blister with soapy water, then pat the area dry.
Put Neosporin or Triple Antibiotic Ointment on the wound, then cover it with nonstick gauze. Use medical tape or Coban to hold the gauze on. You can also use a large Band-Aid that covers the blister.
This web link for the Mayo Clinic has good advice about blister care: http://www.mayoclinic.org/first-aid/first-aid-blisters/basics/art-20056691http://www.mayoclinic.org/first-aid/first-aid-blisters/basics/art-20056691[/shorthand][shorthand name="blt"]bilateral[/shorthand][shorthand name="blty"]bilaterally[/shorthand][shorthand name="bmicms"]BMI between 23 and 30. Within goal range per CMS guidelines.[/shorthand][shorthand name="bmp"]Your kidney test shows that your kidneys are working normally. Your electrolytes (minerals like sodium [salt], potassium, and calcium) are normal.[/shorthand][shorthand name="bmpabnml"]Your kidney test shows that your kidneys are not working as well as they should. [/shorthand][shorthand name="bmpbetter"]Your kidney test shows that your kidneys are working better than last time.[/shorthand][shorthand name="bmpstable"]Your kidney test shows that your kidneys are working about the same as they were last time.[/shorthand][shorthand name="bmpworse"]Your kidney test shows that your kidneys are not working as well as last time.[/shorthand][shorthand name="bnp"]Your BNP test, the test that measures how hard your heart is working, shows that your heart is working normally.[/shorthand][shorthand name="bnphigh"]Your BNP test, the test that measures how hard your heart is working, shows that your heart is working a little harder than normal. This can cause fluid to build up in your legs and your lungs.[/shorthand][shorthand name="bonedensitynormal"]Your bone density test was normal.[/shorthand][shorthand name="bowr "]the benefits outweigh the risks[/shorthand][shorthand name="bp"]blood pressure[/shorthand][shorthand name="bpgoal"]Patient's blood pressure is at goal of 139/89 or less. Condition is stable. Continue current medications and treatment plan.
I recommend that you exercise for 30-45 minutes 5 days a week.
I also recommend a balanced diet with fruits and vegetables every day, lean meats, and little fried foods. The DASH diet (you can find this online) is a good example of this.[/shorthand][shorthand name="bpgoal60+"]Patient's blood pressure is at goal of 149/89 or less (goal for 60+ per AGS). Condition is stable. Continue current medications and treatment plan.
I recommend that you exercise for 30-45 minutes 5 days a week.
I also recommend a balanced diet with fruits and vegetables every day, lean meats, and little fried foods. The DASH diet (you can find this online) is a good example of this.[/shorthand][shorthand name="bphigh"]Blood pressure is elevated above goal of <140/90. Will adjust medication and encourage diet and lifestyle modification to achieve goal of < 140/90.I also recommend a balanced diet with fruits and vegetables every day, lean meats, and little fried foods. The DASH diet (you can find this online) is a good example of this.[/shorthand][shorthand name="bplog"]Check your blood pressure 3-4 times a week. Write them down and bring that blood pressure log to your next appointment. Notify me if your blood pressure stays over 140/90.[/shorthand][shorthand name="breastcancerscreening"]Patient counseled about the pros and cons of breast cancer screening.  She elected to defer screening at this time.[/shorthand][shorthand name="bruisingseninors"]ESSENTIALS FOR OLDER PEOPLE:
Older people may be more prone to easy bruising. As people age, the skin thins and people lose some of the protective layer of fat below the skin surface, so a minor bump is more likely to cause blood vessels to break, leading to bruising. Also, the small blood vessels themselves become less elastic and more fragile, leading to easier bruising. Older people also are more likely to take aspirin, clopidogrel, warfarin, or direct oral anticoagulants, which make bruising and bleeding more likely.
KEY POINTS:
Excessive bleeding may occur on its own or after minor injury.
Bleeding can range from minimal to massive and is very dangerous if it occurs within the brain.
Liver disease, low platelet count, and certain drugs (especially warfarin, heparin, aspirin, and NSAIDs ) are common causes.
Disseminated intravascular coagulation is an uncommon but serious cause that most often develops in people who are already ill or in the hospital.
Easy bruising is common and is rarely a cause for concern if people feel well and have no other signs of easy bleeding.[/shorthand][shorthand name="bu"]back up[/shorthand][shorthand name="bx"]biopsy[/shorthand][shorthand name="ca"]cancer[/shorthand][shorthand name="calc"]Your calcium level was normal this time.[/shorthand][shorthand name="calchigh"]Your calcium level was higher than normal this time.[/shorthand][shorthand name="calciumdiet"]You can get extra calcium by drinking or eating these things: milk, yogurt, or cheese. Eight (8) ounces of cheese contains 300 mg of calcium. Your body needs 1,200 to 1,500 mg of calcium a day.[/shorthand][shorthand name="caloriecount"]Eating ________ calories a day will keep your weight the same.
Eating 250 fewer calories a day will help you lose 1/2 pound a week.
Eating 500 fewer calories a day will help you lose 1 pound a week.[/shorthand][shorthand name="capturecopd"]CAPTURE (COPD) screening test score = _____.
Based on score, select 1 of 3 options:
A) Score = 0-1, patient is Low Risk for COPD. No further testing needed.
B) Score = 2-4, patient is Intermediate Risk for COPD. Do PEF. If PEF < 350 (men) or < 250 (women), patient is High Risk for COPD. Do post bronchodilator spirometry. If PEF >/= 250 (women), >/+ 350 (men), patient is Low Risk for COPD. No further testing needed.
C) Score = 5-6, patient is High Risk for COPD. Schedule post bronchodilator spirometry.[/shorthand][shorthand name="carotidus"]The ultrasound of your carotid arteries showed no narrowing or plaques.[/shorthand][shorthand name="cbc"]Your complete blood count was normal. You are not anemic. Your white blood cell count (infection fighters) and your platelets (blood clotting cells) were normal.[/shorthand][shorthand name="cbcanemia"]Your complete blood count shows that you are anemic. Your white blood cell count (infection fighters) and your platelets (blood clotting cells) were normal.[/shorthand][shorthand name="cbcnormal"]I reviewed the results of your complete blood count.
You are not anemic.
Your white blood cell count (infection fighters) is normal.
Your platelet count (blood clotting cells) is normal.[/shorthand][shorthand name="cbcplatelet"]Your complete blood count showed the following: 
You are not anemic.
Your white blood cell count (infection fighters) is normal.
Your platelets (blood clotting cells) count is low. It is _______. A normal count is 140,000 to 400,000. A platelet count above 100,000 does not need further testing or treatment, but does need to be monitored each year.[/shorthand][shorthand name="cbcwbc"]Your complete blood count shows that your white blood cell count (infection fighters) is higher than normal. Your platelets (blood clotting cells) were normal. You are not anemic.[/shorthand][shorthand name="cchpi"]Patient presents to the clinic today with the following concern(s):
1)
2)
3)[/shorthand][shorthand name="ccp"]Your blood test for rheumatoid arthritis (CCP test) was negative (normal).[/shorthand][shorthand name="cd"]could[/shorthand][shorthand name="cellulitis"]Take the antibiotics I prescribed for your skin infection.
Rinse the area with soapy water.
Contact us if the redness has not gone away by the time you finish the antibiotics or if you get high fevers (more than 100 degrees) or shaking chills.[/shorthand][shorthand name="cg "]copy given to patient[/shorthand][shorthand name="chk"]check[/shorthand][shorthand name="choladvice"]Exercising, eating low fat, low cholesterol foods, and losing weight will help improve your cholesterol numbers.[/shorthand][shorthand name="cin"]Will call if normal and call for follow-up appointment if abnormal[/shorthand][shorthand name="circn"]circulation[/shorthand][shorthand name="ck"]Your test for muscle inflammation was negative (normal). There were no signs of damaged muscle tissue.[/shorthand][shorthand name="ckd"]Your kidney test shows that your kidneys are not working as well as they should. Controlling chronic diseases protect your kidneys.[/shorthand][shorthand name="ckdhpi"]Chronic kidney disease: Patient has CKD stage 1 (eGFR >/= 90) / stage 2 (eGFR 60-89) / stage 3a (eGFR 45-59) / stage 3b (eGFR 30-44) / stage 4 eGFR 15-29) / stage 5 (eGFR <15).
Last eGFR ____ . Vitamin D normal / low. Phosphorus normal. Parathyroid hormone normal / high.[/shorthand][shorthand name="ckhigh"]Your test for muscle inflammation was positive (higher than normal). This means your muscles are inflamed.[/shorthand][shorthand name="cmp"]Your liver and kidney tests were normal.[/shorthand][shorthand name="cnf"]contact patient, needs follow up[/shorthand][shorthand name="cologuardnegative"]Your Cologuard test was negative (normal). You need to have this test done again in 3 years.[/shorthand][shorthand name="cologuardpositive"]Your Cologuard test was positive. This means you may have a precancerous polyp (advanced adenoma) or colon cancer. Because the Cologuard test cannot tell for certain, I recommend that you get a colonoscopy to look at your colon more carefully. I will refer you to a gastroenterologist for this.[/shorthand][shorthand name="coloncancerscreening"]Patient was counseled about risks, benefits, and alternatives to colon cancer screening.[/shorthand][shorthand name="constipation"]For your constipation:
Take Colace (docusate) 100mg 1 pill once a day to soften your stools.
Try Benefiber (fiber laxative) 1 scoop in a glass of water or juice if you have had a stool in 2 days.
If that makes you too gassy, try MiraLax. Mix 1 scoop in a glass of water or juice once a day.
Drink at least six 12-ounce glasses of water each day.
Eat fruits and vegetables each day.
You can also try high fiber cereals like Uncle Sam's bran cereal.
I prescribed a stronger laxative called Dulcolax for you. Take 1 pill a day as needed if you still have not had a bowel movement. Stop taking it if you get diarrhea or painful stomach cramps.
If you are not moving your bowels every 2-3 days after 2 weeks of trying this, contact us.
Also contact us if you stop passing gas.[/shorthand][shorthand name="contemplation"]Patient is currently in the contemplation stage of change.[/shorthand][shorthand name="continuousOCP"]Start your next pack of Sprintec as you normally would and take all the pills for the 1st 3 weeks. Most pill packs will then have a week of sugar pills, during which time you would normally have your period. Throw those sugar pills away and start your next pack of Sprintec the next day. Take the next 3 weeks of pills every day -- never miss a pill. Skip the 7 sugar pills in each of the first 3 packs of Sprintec. Then start the 4th pack, take the 21 active (hormone) pills 1 pill a day for 21 days. Then take the 7 sugar (non hormone ) pills 1 pill a day for 1 week. During this week you will have your period. After that week is done, start taking the active Sprintec pills for 84 days (4 packs) as you did above. You will usually have a period 4 times a year. Start the bupropion pill once a day for your moods. Come back to see me in 1 month to see how these medicines are working for you.[/shorthand][shorthand name="controlledrx3"]I sent 3 prescriptions for your ADHD medicine to your pharmacy.  The first prescription will be sent today ( __________ ).  The 2nd prescription will be sent on __________, and the 3rd prescription will be sent on __________.[/shorthand][shorthand name="controlledsubstanceagreement"]Controlled substance agreement signed by patient, then scanned into patient's chart.[/shorthand][shorthand name="copdexacerbation"]Treat as bacterial exacerbation of chronic bronchitis with antibiotics, oral steroids, and inhaled SABA prn cough, wheezing, and SOB. Continue maintenance COPD meds[/shorthand][shorthand name="copdrescuepack"]I sent a prescription for a COPD Rescue Pack to your pharmacy. The Rescue Pack includes prednisone (steroid) pills and an antibiotic. Start taking these 2 medicines if you are coughing up yellow or green phlegm (mucus) or your shortness of breath and wheezing get worse. If you start feeling better, you do not need to start these 2 medicines.[/shorthand][shorthand name="cortisol"]Your body makes a normal amount of cortisol (an important hormone that helps control your blood pressure and metabolism).[/shorthand][shorthand name="cpapmedicare"]Patient was seen in the office today to assess sleep apnea and use of CPAP. The patient is benefitting from use of CPAP and needs to continue to use it. CPAP has improved patient's sleep apnea and improved control of comorbid conditions. Records of CPAP machine usage were reviewed. Patient is using CPAP machine daily,[/shorthand][shorthand name="cpe"]It was nice to meet you today.
I recommend that you exercise for 30-45 minutes 5 days a week. I also recommend a balanced diet with fruits and vegetables every day, lean meats, and little fried foods. The DASH diet (you can find this online) is a good example of this.
I will post your lab results to the patient portal. If you have not been contacted about your test results by 2 weeks from now, then please contact us.
Come back in 1 year for your annual physical or sooner if needed[/shorthand][shorthand name="cpeptide"]Your C-peptide test (a measure of how much insulin your body makes) shows your body is still making insulin.[/shorthand][shorthand name="cpm"]Continue the present management of condition.[/shorthand][shorthand name="crb"]Colonoscopy reviewed in detail, including prep and procedure, risks and benefits of detection, and prevention of colon cancer.[/shorthand][shorthand name="crp"]Your test for severe inflammation in your body was negative (normal).[/shorthand][shorthand name="crphigh"]Your test for severe inflammation in your body was higher than normal.[/shorthand][shorthand name="cryosurgery2"]Today we used a cold, liquefied gas to remove superficial skin growths like warts and keratoses.
You will probably feel some stinging and mild pain, but this will not last long. If you have a growth removed from your forehead, some throbbing may persist. If so, you can relieve this with aspirin or Tylenol. After the treatment, your skin will become red and swollen and will develop a blister. Healing takes one to three weeks, after which the skin may look perfectly normal or slightly lighter in color.
After the procedure:
• Clean the treated area with rubbing alcohol or with soap and water as you normally would. It is fine to get the area wet; however, be sure to blot it dry carefully and delicately.
• If necessary, you can open the blister with a sterilized needle.
• Apply a thin layer of antibiotic ointment such as Bacitracin or Polysporin to the site twice daily.
• If the site is prone to irritation, cover it with a bandage.
• You will likely see a scab form after a few days. This crust will fall off on its own. A second scab may form as well, and it too will shed on its own.
• If the treated site becomes thickened, tender or raised, call your family doctor for advice. This can happen even several months after the procedure, most often in the neck or upper trunk areas.[/shorthand][shorthand name="CThead"]The CT (cat scan) of your head and brain were normal.[/shorthand][shorthand name="cvat"]costo-vertebral angle tenderness[/shorthand][shorthand name="cvdrisk"]You have a ____% chance of having a heart attack or stroke in the next 10 years. The American Heart Association guidelines recommend that you take a cholesterol lowering medicine (statin) to lower this risk. I want you to start taking ______.[/shorthand][shorthand name="cxr"]chest X-ray[/shorthand][shorthand name="cxrnl"]Your chest x ray was normal.[/shorthand][shorthand name="dcd"]discharged[/shorthand][shorthand name="ddimer"]Your D dimer test (test for deep vein blood clots, also called DVTs) was negative. This is a normal result.[/shorthand][shorthand name="declinedtest"]Patient declined recommended screening test.[/shorthand][shorthand name="def "]deficiency[/shorthand][shorthand name="dehydrated"]Your kidney tests show that you are dehydrated. Try to drink at least six 12-ounce glasses of water (or other liquids) each day.[/shorthand][shorthand name="dementia"]Living with dementia:
• Agree, instead of arguing
• Divert, instead of reasoning
• Distract, instead of shaming
• Reassure, instead of lecturing
• Reminisce, instead of saying remember
• Repeat, instead of saying I told you
• Do what they can do, instead of saying you can't
• Ask, instead of demanding
• Encourage, instead of condescending
• Reinforce, instead of forcing[/shorthand][shorthand name="depoprovera"]Come back to the clinic in 3 months (12 weeks) for your next Depo Provera (birth control) shot.[/shorthand][shorthand name="dhea"]Your test for the male hormone DHEA sulfate was normal.[/shorthand][shorthand name="dietexed"]I recommend that you exercise for 30-45 minutes 5 days a week. I also recommend a balanced diet with fruits and vegetables every day, lean meats, and little fried foods. The DASH diet (you can find this online) is a good example of this.[/shorthand][shorthand name="diethx"]Please complete the 3-day diet history form I gave you. We will review this at your next visit.[/shorthand][shorthand name="dips"]distal interphalangeal joints[/shorthand][shorthand name="discn"]discussion[/shorthand][shorthand name="dmed"]Education provided re: diabetes pathophysiology and management, including effectiveness of diet, exercise, and medication in controlling sugar and preventing complications, as well as information on the complications and recommended care. [/shorthand][shorthand name="dmplan"]Check labs and adjust medications to reach A1C goal.[/shorthand][shorthand name="dmstable"]Diabetes mellitus 2 well controlled on current regimen. Last A1C <7.0%. Continue current treatment.[/shorthand][shorthand name="dmsugargoal"]I want your fasting morning blood sugar to be less than 100. 
I want your sugar to be less than 140 two hours after a meal.[/shorthand][shorthand name="dx"]diagnosis[/shorthand][shorthand name="earwax"]You can use drops to soften the wax in your ears.
Then use a bulb syringe to remove the wax.
You can buy ear wax removal kits at your pharmacy without a prescription. You can use a brand like Debrox Earwax Removal.[/shorthand][shorthand name="earwaxoil"]Try almond oil, olive oil, or mineral oil. 3-4 drops 3-4 times daily for 3-5 days. Gently rinse out wax with baby bulb syringe and room temperature tap water.[/shorthand][shorthand name="ecg"]Your ECG (heart test) was normal.[/shorthand][shorthand name="ecre"]In addition, encouraged regular exercise and to consider counseling.[/shorthand][shorthand name="eczemacare"]Eczema care discussed including avoidance of hot showers and strong soaps or detergents to wash clothes, use of emollients with occasional use of topical prescription steroids if needed. Role of allergens also reviewed. [/shorthand][shorthand name="edn "]education[/shorthand][shorthand name="eia"]exercise induced asthma[/shorthand][shorthand name="ekgnormal"]Normal sinus rhythm. No acute ST or T-wave changes. Normal EKG.[/shorthand][shorthand name="emb"]endometrial biopsy[/shorthand][shorthand name="embpn"]Post-consent, cervix cleansed with Betadine and tenaculum applied to anterior lip. Uterus sounded to 4 1/2 cms and sampler introduced. Tissue sample obtained. Patient tolerated well. Sample sent to pathology.[/shorthand][shorthand name="eocu"]education on consequences of untreated[/shorthand][shorthand name="esp"]especially[/shorthand][shorthand name="esr"]Your sed rate (blood test for inflammation) was normal.[/shorthand][shorthand name="estradiollow"]Your estradiol (a type of estrogen, the main female hormone) level was low. This is normal for women who have gone through menopause.[/shorthand][shorthand name="estrogenmenopause"]Your total estrogen (the main female hormone) level was normal for a woman who has gone through menopause.[/shorthand][shorthand name="estrogennormal"]Your total estrogen (the main female hormone) level was normal.[/shorthand][shorthand name="etohed"]Patient advised to reduce alcohol consumption to the lower recommended levels (1 drink/day or less for women, 2 drinks/day or less for men).[/shorthand][shorthand name="etohmale"]Patient advised to reduce alcohol intake to two 12-ounce beers a day, or less[/shorthand][shorthand name="excisioncare"]Keep the bandage on for 24 hours, then change it daily. Put 4x4-inch nonstick gauze pad on the incision with paper tape. Do not get the area wet for 24 hours. You can then rinse the area with soapy water, pat the area dry, and cover it with the bandage. Come back in 7-10 days to remove your stitches. Call me if you have increased pain, bleeding, redness, fever, or other concerns.[/shorthand][shorthand name="familydocorg"]Gave patient handout from familydoctor.org (AAFP) patient education.[/shorthand][shorthand name="fattyliver"]Your liver ultrasound showed fatty liver. This means that your body is storing extra fat in your liver. Losing weight will help this.[/shorthand][shorthand name="fdz"]Review of breast texture and nature of fibrocystic breast condition. I explained that breasts that are more dense in texture can be harder to do an exam on, and that mammograms can miss breast cancers. I also explained that women with this breast texture do seem to have more breast cancers diagnosed. There is not as yet an agreed upon better test in this situation. [/shorthand][shorthand name="ferr"]Your ferritin level is normal. This means that you are storing enough iron in your bones.[/shorthand][shorthand name="fhx"]family history[/shorthand][shorthand name="FIT"]Patient declines colonoscopy, understanding that it's the better test for detection of colon cancer, but will do fecal immunochemical test for hemoglobin in stool, InSure FIT. Use explained. [/shorthand][shorthand name="FITneg"]Your stool blood test showed no signs of blood in your stool. This is a normal result. You will need to repeat this test in 1 year to check again for signs of colon cancer.[/shorthand][shorthand name="FITpos"]Your stool blood test showed microscopic blood in your stool. Please contact me to discuss this result further. If you already have an appointment in the clinic in the next 1-2 weeks, keep that appointment.[/shorthand][shorthand name="flu"]You have the flu (influenza).
Take Tamiflu (oseltamivir) for the flu. 
Take Mucinex DM or Robitussin DM as needed for cough and congestion.
You can also try Flonase Allergy 2 sprays to each nostril once a day for congestion.
You can also try salt water nose spray for stuffy nose.
If you do not have high blood pressure or heart problems, you can try Sudafed or similar decongestants for congestion.
You can take Claritin or Zyrtec as needed for drainage.
Take over the counter acetaminophen or ibuprofen as needed for pain, body aches, fever, or chills.
You can try throat lozenges or salt water gargles for any sore throat. 
Your symptoms may take 7-10 days to go away.
Drink lots of fluids. Get plenty of rest.
Contact us if you have worsening symptoms such as high fever (102F), shortness of breath, inability to keep liquids and solids down, or other worsening symptoms. Contact us if your symptoms fail to improve after 10 days. 
If your symptoms get worse after the clinic is closed, you can call our office to reach the on-call doctor.[/shorthand][shorthand name="flued"]Education re: value and effectiveness of flu vaccine, lack of significant side effects, will not cause URI symptoms which likely originate in other cold viruses (cannot protect against other viruses), lack of ideal effectiveness, but able to prevent transmission to high-risk individuals. Strongly encouraged to get annually. [/shorthand][shorthand name="fms"]fibromyalgia syndrome[/shorthand][shorthand name="fobt"]Your stool blood test (screening test for colon cancer) was negative. This is a normal result.[/shorthand][shorthand name="folicacid"]You have a normal amount folic acid vitamin in your body.[/shorthand][shorthand name="folicacidRBC"]You have normal amounts of folic acid vitamin in your red blood cells.[/shorthand][shorthand name="freepsa"]Your total PSA (prostate cancer screening test) and free PSA (additional prostate cancer screening test) were normal.[/shorthand][shorthand name="fsh"]Your FSH (hormone the body makes to control the ovaries and testicles) was normal.[/shorthand][shorthand name="fshlhmenopause"]Your FSH (hormone the body makes to control the ovaries and testicles) was high. This is normal for a woman who has gone through menopause.
Your LH (hormone the body makes to control the ovaries and testicles) was high. This is normal for a woman who has gone through menopause.[/shorthand][shorthand name="g25"]Greater than 50% of this 25-minute visit was spent counseling the patient on:[/shorthand][shorthand name="gbp"]gastric bypass surgery[/shorthand][shorthand name="gc2"]Your tests for gonorrhea and chlamydia (sexually transmitted infections) showed the following:
You DO NOT have gonorrhea.
You DO NOT have chlamydia.[/shorthand][shorthand name="gediet"]Refeeding info given including clear liquids such as broths or sports drinks, gradual advance to starchy bland foods such as rice, toasted white bread, bananas, etc., avoidance of cheese or milk for 4 to 5 days but yogurt OK and probiotics encouraged, and avoidance of fried, greasy, and spicy foods or thick juices. [/shorthand][shorthand name="gerded"]Avoid meals too near bedtime, watch portion sizes and acidic foods, and avoid caffeine, chocolate, and fatty foods if they worsen GERD symptoms. Can try raising head of bed with books or blocks under mattress, and weight loss can help for some. [/shorthand][shorthand name="ggt"]Your GGT test (a liver test) was normal.[/shorthand][shorthand name="glucometered"]Glucometer education and prescription provided, including goal numbers and frequency of testing.[/shorthand][shorthand name="glycemicindex"]Gave patient handout on glycemic index. Advised choosing more foods with low glycemic index.[/shorthand][shorthand name="goodrx"]Go to www.goodrx.com to look for coupons for your medicines and to check prices.[/shorthand][shorthand name="gs"]gall stones[/shorthand][shorthand name="gtt"]I want to do a special blood sugar test to see if you have developed diabetes. You will need to fast overnight before the test. You can drink water. When you come in for the test, we will check your blood sugar. We will then give you a sweet drink. After that we will check your sugar once an hour for 2 hours.[/shorthand][shorthand name="gttresult"]Your 2-hour blood sugar test did not show diabetes. [/shorthand][shorthand name="ha"]headache[/shorthand][shorthand name="hepa"]Your test for acute hepatitis A was negative. You do not have evidence of hepatitis A infection in your body.[/shorthand][shorthand name="hepatitisABCpanelnml"]Your tests for hepatitis A, B, and C were negative. You do not have evidence of hepatitis A infection, hepatitis B infection, or hepatitis C in your body.[/shorthand][shorthand name="hepb"]Your test for hepatitis B virus was negative. You do not have evidence of hepatitis B infection.[/shorthand][shorthand name="hepbimmune"]Your test for antibodies against hepatitis B virus was positive. This means you are immune to hepatitis B.[/shorthand][shorthand name="hepbviral"]Your hepatitis B viral load is undetectable. There is no detectable virus in your body.[/shorthand][shorthand name="hepc"]Your test for hepatitis C was negative. You do not have evidence of hepatitis C in your body.[/shorthand][shorthand name="hepcviralload"]Your hepatitis C viral load is undetectable. There is no detectable virus in your body.[/shorthand][shorthand name="hf"]has follow-up appointment[/shorthand][shorthand name="hfau"]HFA inhaler use taught/demonstrated, including care, priming, breathing technique, and use of spacer. Patient demonstrated back correct technique.[/shorthand][shorthand name="hipxr"]The x-ray of your right hip was normal. It did not show any fractures or arthritis.[/shorthand][shorthand name="hiv"]Your test for HIV was negative. You do not have evidence of HIV in your body.[/shorthand][shorthand name="hm"]health maintenance[/shorthand][shorthand name="ho "]handout[/shorthand][shorthand name="homocysteine"]Your homocysteine level was normal. If your body is not making enough folic acid, your homocysteine level will be high.[/shorthand][shorthand name="hpained"]Stretches demonstrated to do daily, NSAIDS if tolerated short-term, weight management, and a night splint for heel pain if not improving. Recommendations for heel pain: wear shoes with a good heel support or use a silicone heel insert, ice baths for 10 minutes twice daily.[/shorthand][shorthand name="hpi"]See HPI for details.[/shorthand][shorthand name="hpicpx"]Patient presents to the clinic today for annual physical.[/shorthand][shorthand name="hpiphysical"]Patient presents to the clinic today with the following concern(s):
1) Annual physical
2)
3)[/shorthand][shorthand name="hpl"]hyperlipidemia[/shorthand][shorthand name="hpo"]hypothyroidism[/shorthand][shorthand name="hpylorinml"]Your breath test did not show any evidence of H pylori bacteria infection. H pylori is the bacteria that causes gastritis (stomach irritation from too much acid) and ulcers.[/shorthand][shorthand name="hpyloripositive"]Your breath test showed evidence of H pylori bacteria infection. H pylori is the bacteria that causes gastritis (stomach irritation from too much acid) and ulcers. I will send prescriptions for acid medicine and antibiotics to take for this. This should help your acid reflux and heartburn.[/shorthand][shorthand name="hscrp"]Your high sensitivity C reactive protein test showed that your relative cardiovascular risk is LOW AVERAGE HIGH.[/shorthand][shorthand name="hsv1igg"]Your herpes simplex 1 IgG titer was negative (normal).[/shorthand][shorthand name="hsv1igm"]Your herpes simplex 1 IgM titer was negative (normal).[/shorthand][shorthand name="hsv2igg"]Your herpes simplex 2 IgG titer was negative.[/shorthand][shorthand name="hsv2igm"]Your herpes simplex 2 IgM titer was negative (normal).[/shorthand][shorthand name="hsz"]hospitalization[/shorthand][shorthand name="htn"]hypertension[/shorthand][shorthand name="hx"]history[/shorthand][shorthand name="ibs "]irritable bowel syndrome[/shorthand][shorthand name="iceheat"]Put ice on the affected limb for 15 minutes every 1-2 hours as needed for pain and swelling. If this does not help then stop using ice.
Use a heating pad on the affected limb for 20 minutes every 1-2 hours as needed.[/shorthand][shorthand name="ide"]Importance of diet and exercise reviewed.[/shorthand][shorthand name="imagingresult"]Interpretation entered. Report placed for scanning.[/shorthand][shorthand name="immutd"]Immunization up to date.[/shorthand][shorthand name="improved"]Condition has improved. Continue current treatment plan.[/shorthand][shorthand name="inr"]Your INR test shows that your coumadin (Warfarin) is working. Your blood is just as thin as I want it to be. Keep taking the same dose of coumadin (Warfarin). You need to come back for another INR blood test in 1 month. I entered a lab order for you. You do not need to fast for this test.[/shorthand][shorthand name="inrhigh"]Your INR test shows that your blood is thinner than I want it to be. Change your dose of coumadin (Warfarin) as follows: ___ You need to come back for another INR blood test in ____ month. I entered a lab order for you. You do not need to fast for this test.[/shorthand][shorthand name="inrlow"]Your INR test shows that your blood is not as thin as I want it to be. Change your dose of coumadin (Warfarin) as follows: ___ You need to come back for another INR blood test in ____ week(s). I entered a lab order for you. You do not need to fast for this test.[/shorthand][shorthand name="ins"]insurance[/shorthand][shorthand name="insulinslidingscale"]Check your blood sugar every morning before breakfast.
Change your daily total insulin dose as described below:
• IF your morning blood sugar is more than 180, THEN increase total daily insulin by 6 units,
• IF your morning blood sugar is between 141 and 180, THEN increase total daily insulin by 4 units,
• IF your morning blood sugar is between 121 and 140, THEN increase total daily insulin by 2 units,
• IF your morning blood sugar is between 100 and 120, THEN increase total daily insulin by 1 unit,
• IF your morning blood sugar is less than 80, THEN decrease total daily insulin by 2 units.
*ONLY CHANGE YOUR INSULIN DOSE EVERY 3 DAYS*[/shorthand][shorthand name="insulinslidingscalesimple"]Check you blood sugar every morning. Increase your total daily insulin dose by 2 units every 3 days until your morning fasting blood sugar is less than 100.[/shorthand][shorthand name="insulintitration"]Check your blood sugar in the morning before breakfast. If your morning fasting blood sugar is more than 100 for 1 week, increase your total daily insulin dose by 1 unit. If your fasting blood sugar is still more than 100 after 1 week, then keep increasing your total daily insulin dose once a week by 1 unit until your morning fasting blood sugar is less than 100.[/shorthand][shorthand name="ionizedcalcium"]Your ionized calcium level (the amount of calcium circulating in your blood) was normal this time.[/shorthand][shorthand name="ionizedcalciumhigh"]Your ionized calcium level (the amount of calcium circulating in your blood) is higher than normal.[/shorthand][shorthand name="iron"]You have normal levels of iron in your body.[/shorthand][shorthand name="ironlow"]The amount of iron in your body is lower than normal.[/shorthand][shorthand name="itching"]For the itching, take Zyrtec 10 mg 1 pill each night. You can also try Benadryl Allergy, Benadryl cream, or calamine lotion as needed for itching.[/shorthand][shorthand name="IUDses"]Review of IUD insertion including risk of uterine perforation, infection, or bleeding. Discussed benefits of Paragard and Mirena IUDs including long-term effectiveness, decreased bleeding or prolonged amenorrhea with Mirena, and increased bleeding, cramping, and discharge with Paragard, low failure rates but increased tubal pregnancy risk with failure, and risks of spontaneous expulsion, scarring with tubal occlusion and infertility, and pelvic infections.[/shorthand][shorthand name="iup"]pregnancy[/shorthand][shorthand name="ix"]investigation[/shorthand][shorthand name="jnc8lifestyle"]National guidelines on treating high blood pressure recommend the following: 1) Follow the Dietary Approaches to Stop Hypertension (DASH) eating plan, weight loss, 2) Consume less than 2.4 grams per day, 3) Get at least 30 minutes of aerobic activity 3-4 days a week, 4) Limit alcohol use to 2 drinks daily in men and 1 drink daily in women (1 drink = 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor), and 5) If you smoke, quit smoking.[/shorthand][shorthand name="jointinjectionhpi"]Patient presents today for planned injection of right | left | both knee(s) | shoulder(s) due to persistent pain not relieved by conservative treatment. Risks, benefits, and alternatives of the procedure were explained to the patient. Consent was signed. All questions were answered.[/shorthand][shorthand name="labfu"]Please come back to the clinic for some more lab tests. I put lab orders at the front desk for you. You do not need to fast. You do not need an appointment.[/shorthand][shorthand name="lan"]lymphadenopathy[/shorthand][shorthand name="ldh"]Your LDH blood test (a test that shows if there are possible problems in your liver or your blood) was normal.[/shorthand][shorthand name="legstretchingexercises"]Gave handout on stretching exercises for the lower body.[/shorthand][shorthand name="lft"]Your liver tests are normal.[/shorthand][shorthand name="lfthigh"]Your liver tests are higher than normal.[/shorthand][shorthand name="lftlower"]Your liver tests are higher than normal, BUT they are lower than they were last time.[/shorthand][shorthand name="lh"]Your LH (hormone that the body makes to control the ovaries and testicles) was normal.[/shorthand][shorthand name="lipase"]Your lipase (pancreas enzyme that helps digest food) was normal. This means that your pancreas is not inflamed.[/shorthand][shorthand name="lipidabnormal"]I reviewed the results of your cholesterol test. The following results are abnormal:
Your total cholesterol is more than 200.
Your good (HDL) cholesterol is less than 40.
Your bad (LDL) cholesterol is more than 130.
Your triglycerides (fat dissolved in your blood) is more than 150.
Exercising, eating low-fat, low-cholesterol foods, and controlling your weight will help control your cholesterol numbers.[/shorthand][shorthand name="lipidcvdrisk"]Your total cholesterol is ____. It should be less than 200.
Your good (HDL) cholesterol is ____. It should be more than 40.
Your bad (LDL) cholesterol is ____. It should be less than 100.
Your triglycerides (fat dissolved in your blood) is ____. It should be less than 150.
Your LDL (bad) cholesterol is / is not where it should be. Continue your current treatment.
Exercising, eating low-fat, low-cholesterol foods, and losing weight will help improve your cholesterol numbers.
You have a ____ % chance of having a heart attack or stroke in the next 10 years. The American Heart Association guidelines recommend that you take a cholesterol-lowering medicine (statin) to lower this risk. I want you to start taking ______.[/shorthand][shorthand name="lipiddmresult"]Your total cholesterol is ____. It should be less than 200.
Your good (HDL) cholesterol is ____. It should be more than 40.
Your bad (LDL) cholesterol is ____. It should be less than 100.
Your triglycerides (fat dissolved in your blood) is ____. It should be less than 150.
Your LDL (bad) cholesterol is / is not where it should be. Continue your current treatment.
Exercising, eating low-fat, low-cholesterol foods, and losing weight will help improve your cholesterol numbers.[/shorthand][shorthand name="lipidgoal"]LDL is at goal of less than 100. Continue current dose of statin therapy.[/shorthand][shorthand name="lipidnormal"]I reviewed the results of your cholesterol test. The following results are normal:
Your total cholesterol is less than 200.
Your good (HDL) cholesterol is more than 40.
Your bad (LDL) cholesterol is less than 130.
Your triglycerides (fat dissolved in your blood) is less than 150.
Continue your current treatment.
Exercising, eating low-fat, low-cholesterol foods, and controlling your weight will help control your cholesterol numbers.[/shorthand][shorthand name="lipidplan"]Check labs and adjust current medications to reach goal lipid levels. [/shorthand][shorthand name="lipidresults"]I reviewed the results of your cholesterol test.
The following results are normal:
Your total cholesterol is less than 200.
Your good (HDL) cholesterol is more than 40.
Your bad (LDL) cholesterol is less than 130.
Your triglycerides (fat dissolved in your blood) is less than 150.
The following results are abnormal:
Your total cholesterol is more than 200.
Your good (HDL) cholesterol is less than 40.
Your bad (LDL) cholesterol is more than 130.
Your triglycerides (fat dissolved in your blood) is more than 150.
Continue your current treatment.
Exercising, eating low-fat, low-cholesterol foods, and controlling your weight will help control your cholesterol numbers.[/shorthand][shorthand name="liver"]Your liver tests are normal.[/shorthand][shorthand name="liverultrasound"]The ultrasound of your liver showed that your liver and gallbladder were normal.[/shorthand][shorthand name="llq "]left lower quadrant[/shorthand][shorthand name="lmr"]left more than right[/shorthand][shorthand name="lth"]levothyroxine[/shorthand][shorthand name="lunccancerscreening"]The U.S. Preventive Services Task Force recommends yearly lung cancer screening with LDCT for people who:
1) Have a history of heavy smoking (30 pack yrs or more) AND
2) Smoke now or have quit within the past 15 years AND
3) Are between 55 and 80 years old.[/shorthand][shorthand name="luq"]left upper quadrant[/shorthand][shorthand name="ma"]medical assistant[/shorthand][shorthand name="mag"]Your magnesium level is normal.[/shorthand][shorthand name="mammo"]Your mammogram was normal. It did not show any signs of breast cancer. You need to get another mammogram in 1 year.[/shorthand][shorthand name="mdn"]medication[/shorthand][shorthand name="medrec"]Medical records reviewed prior to scanning.[/shorthand][shorthand name="menop"]Definition of menopause, expected range of symptoms over time, management with exercise and supplements such as black cohosh for limited use discussed.[/shorthand][shorthand name="metanephrines"]Your urine metanephrines (test for pheochromocytoma) was negative (normal).[/shorthand][shorthand name="mgt"]management[/shorthand][shorthand name="microalbuminnegative"]Your urine kidney test showed no protein in your urine. This is a good result.[/shorthand][shorthand name="microalbuminpositive"]Your urine kidney test showed a small amount of protein in your urine. This can be an early sign of kidney damage. Controlling your diabetes and high blood pressure will help control this.[/shorthand][shorthand name="mindfulnessapp"]Try the smartphone app Mindfulness Coach. This app has many different relaxation techniques. It also can teach you meditation. You can find the app at this web link: https://mobile.va.gov/app/mindfulness-coach[/shorthand][shorthand name="miscflu"]Misconceptions re: influenza vaccination addressed, including that it does not protect against cold and other viruses or illnesses, and does not cause URI-type side effects. Risks and benefits of flu vaccine discussed in detail, and annual vaccination strongly encouraged. I also explained the importance of preventing transmission to other high-risk individuals such as the elderly. [/shorthand][shorthand name="mmg"]mammogram[/shorthand][shorthand name="mmrimmune"]Your are immune to measles, mumps, and rubella (German measles).[/shorthand][shorthand name="mosqprev"]Mosquito bite prevention in general discussed, including use of light full-coverage clothing. May pre-treat clothing with a Sawyer Permethrin Insect repellant spray. Use of mosquito repellants discussed, including DEET varying percentages for clothing and skin, or lemon eucalyptus oil, Repel brand. Diseases such as dengue fever and chikungunya, Japanese encephalitis, etc., require avoidance of bites in addition to malaria prevention.[/shorthand][shorthand name="motrinOTC"]Take ibuprofen (Advil/Motrin) 200 mg 3 pills 3 times a day for 1 week for your pain, then take the ibuprofen 3 times a day as needed.[/shorthand][shorthand name="mribrainw/o"]The MRI of your brain without contrast was normal.[/shorthand][shorthand name="msg"]message[/shorthand][shorthand name="msk"]musculoskeletal[/shorthand][shorthand name="mvi"]multivitamin[/shorthand][shorthand name="newosa"]Discussed with patient the PSG result. Discussion of what an apneic event is, as well as their actual events/O2 sat results. Discussed treatment options including dental appliances, CPAP, and surgery. Discussed the risks of untreated OSA including sudden death, CVA, MI, somnolence leading to MVAs, etc. Patient expressed understanding. Patient has decided to ___.[/shorthand][shorthand name="nexplanonconsentremoval"]Here for removal of Nexplanon. Understands risks of removal, including infection, hemorrhage, scarring, pain at site, damage to structures including nerves and blood vessels, anesthesia reaction, and potential for incomplete removal. Wishes to proceed. [/shorthand][shorthand name="nfcs"]no fevers, chills, or sweats[/shorthand][shorthand name="niacin"]Will start niacin at 500 mg 1 pill daily, and titrate to effect. Counseled patient about flushing. Recommended daily aspirin 81 mg with each niacin pill.[/shorthand][shorthand name="nicotinepatch"]Pick a day to stop using tobacco. That day start using the 21 mg patch.  Use one of the 21-mg patches once a day for 2 weeks. On week 3, start using the 14-mg patch once a day for 2 weeks. On week 5, start using the 7-mg patch once day for 2 week.[/shorthand][shorthand name="nl"]normal[/shorthand][shorthand name="nni"]Notify if not improving or worsening or new symptoms.[/shorthand][shorthand name="nnp"]notify patient, normal pap[/shorthand][shorthand name="nnt"]notify patient, normal tests[/shorthand][shorthand name="nnx"]notify normal X-ray[/shorthand][shorthand name="nsaids"]You can take Tylenol 500mg 1-2 pills 3 times a day for hip pain. You can also take Aleve 220mg 1 - 2 pills twice a day as needed for hip pain.[/shorthand][shorthand name="nsaidses"]Use of NSAIDs causing risks of gastric irritation and ulcers, and kidney damage discussed. [/shorthand][shorthand name="nsb"]no swelling or bruising[/shorthand][shorthand name="occy"]occasionally[/shorthand][shorthand name="ocs"]oral contraceptive pills[/shorthand][shorthand name="OCses"]Discussion was held with the patient re: oral contraception side effects, use, risks, and benefits. [/shorthand][shorthand name="OCuse"]Oral contraception use described as well as description of benefits including lighter menses with less chance of anemia, decreased risk of ovarian cancer, protection against endometriosis, and no increase in appetite or loss of future fertility with low dose OCs. Use condoms as a back up if misses taking OC.[/shorthand][shorthand name="opioiddependence"]Patient must take opioid pain medication on a daily basis to maintain his/her activities of daily living and independent activities of daily living.[/shorthand][shorthand name="osmblood"]The concentration of your blood was normal.[/shorthand][shorthand name="osmurine"]The concentration of your urine was normal.[/shorthand][shorthand name="osteopenia"]Your bone density test showed that you have osteopenia. This means your bones are thinner than normal, but you do not have osteoporosis. I recommend that you take calcium 600mg with vitamin D 400 units twice a day to help keep your bones strong.[/shorthand][shorthand name="osteoporosis"]Your bone density test showed that you have osteoporosis. This means your bones are too thin. I think that you should start taking medicine like alendronate (Fosamax) or risedronate (Actonel) to keep your bones strong. I also recommend that you take calcium 600mg with vitamin D 400 units twice a day to help keep your bones strong.[/shorthand][shorthand name="otc"]over the counter[/shorthand][shorthand name="otcbackpain"]You can take either of these over the counter medicines for back pain: 1) naproxen (Aleve) 220 mg 1-2 pills twice a day as needed for back pain, 2) ibuprofen (Advil/Motrin ) 200 mg 2-3 pills 3 times a day as needed for back pain.[/shorthand][shorthand name="otitisexternadrops"]Mix equal amounts of 30% rubbing alcohol (isopropyl alcohol) with white vinegar. Use a baby bulb syringe to squirt 3-4 drops into each ear after you shower. This will help prevent ear infection.[/shorthand][shorthand name="pap"]Your Pap smear showed no signs of cervical cancer. Your next pap smear is due in 1 year / 3 years / 5 years.[/shorthand][shorthand name="pdmp"]Queried the state Prescription Drug Monitoring Program. Patient is filling prescriptions for controlled substances as intended. 30 day average MME = ____ mg/day.[/shorthand][shorthand name="peakflow"]Patient's estimated Peak Expiratory Flow (PEF)  is ___. Patient's PEF readings are higher / lower than his/her predicted PEF.
Peak flow zones: Green >80% predicted, Yellow 50-80% predicted, Red <50% predicted.[/shorthand][shorthand name="pfm"]peak flow meter[/shorthand][shorthand name="phentermine"]I have prescribed the weight loss medication phentermine. It helps you lose weight by making you less hungry. It can cause side effects such as fast heart rate or elevated blood pressure. Because of this, I want to see you monthly for the first 3 months of treatment. If you have significant side effects or are not able to lose weight after 3 months of treatment, then we will discuss other treatment options.[/shorthand][shorthand name="phos"]Your body has a normal amount of the mineral phosphorus.[/shorthand][shorthand name="phq9neg"]Depression screen was negative.[/shorthand][shorthand name="phq9pos"]PHQ9 screening questionnaire positive for depression. Will discuss in more detail at next office visit.[/shorthand][shorthand name="phy"]pharmacy[/shorthand][shorthand name="physical"]Patient presents to the clinic today with the following concern(s):
1) annual physical
2)
3)[/shorthand][shorthand name="pls"]please[/shorthand][shorthand name="pmhx"]past medical history[/shorthand][shorthand name="pmr"]please mail report[/shorthand][shorthand name="pnc"]prenatal care[/shorthand][shorthand name="pnv"]prenatal vitamin[/shorthand][shorthand name="portal"]You can also check your test results online through our patient portal. Ask our front-office staff to show you how to set this up. You can also send me secure messages about your health.[/shorthand][shorthand name="potass"]Your potassium test was normal.[/shorthand][shorthand name="pothighfood"]Your potassium level is high. Read this handout on foods that have a lot of potassium (http://www.uofmhealth.org/health-library/abo9047). Avoid any of the high potassium foods.[/shorthand][shorthand name="pp"]Planned Parenthood[/shorthand][shorthand name="PPIses"]Long-term side effects of PPIs reviewed, including increased risk of infections such as pneumonia or a type of diarrhea, and poor absorption of calcium leading to osteoporosis.[/shorthand][shorthand name="prealbumin"]Your body is making a normal amount of protein.[/shorthand][shorthand name="preclinic"]Pre-clinic lab orders entered. Patient advised to come to the office prior to his/her appointment for lab tests.[/shorthand][shorthand name="prediabetes"]Your average blood sugar is higher than it should be, but you do not have diabetes. You have PREDIABETES. This means that you have a 5-7% chance of developing diabetes in the next 5 years. Exercising, eating a healthy diet, and losing weight will help keep you from getting diabetes.[/shorthand][shorthand name="pregnancytest"]Your pregnancy test was negative.[/shorthand][shorthand name="preop"]If you are taking aspirin or Plavix (clopidogrel), stop them 1 week before your surgery.
Don't take any ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), or aspirin within a week of surgery.
Stop taking coumadin (Warfarin) 1 week before surgery.
If you take medicine for blood pressure, take your blood pressure medicine the morning of surgery with a small sip of water.
If you take medicine or insulin for diabetes, don't take your diabetes medicines or insulin the night before surgery or the morning of surgery.
Take your other medications normally through the day before surgery.[/shorthand][shorthand name="preopHPI"]Patient here for preoperative evaluation.
Surgeon: 
Surgery: 
Date: 
History of surgical complications (e.g., reactions to anesthesia, infection, excessive bleeding)?[/shorthand][shorthand name="probioticsibs"]Probiotics may improve symptoms in patients with irritable bowel syndrome. Guidelines support probiotics as treatment option for IBS. National Institute for Health and Clinical Excellence (NICE) advises taking probiotics for ≥4 weeks while monitoring effect.
Bifidobacterium bifidum MIMBb75 improves symptoms and quality of life in adults with IBS. 
Bifidobacterium infantis 35624 may reduce some IBS symptoms.
Lactobacillus acidophilus may decrease abdominal pain or discomfort in adults with IBS.
Lactobacillus plantarum 299v (DSM 9843) may reduce overall symptoms, abdominal pain, stool frequency, bloating, and feeling of
incomplete emptying in patients with IBS. 
Lactobacillus rhamnosus GG reduces abdominal pain in children with IBS.[/shorthand][shorthand name="progesterone"]Your progesterone (the other main female hormone) level was also normal for a woman who has gone through menopause.[/shorthand][shorthand name="prolactin"]Your prolactin (hormone your body makes that affects breast tissue in men and women) was normal.[/shorthand][shorthand name="prostate"]Discussed risks, benefits, and alternatives to prostate cancer screening. [/shorthand][shorthand name="psa"]Your prostate cancer screening test (PSA) was normal.[/shorthand][shorthand name="psacounseling"]After discussing the risks and benefits of prostate cancer screening, patient elected to have a PSA test done.[/shorthand][shorthand name="psahigh"]Your prostate cancer screening test (PSA) was higher than normal. Sometimes a prostate infection can cause this. I want you to take antibiotics (ciprofloxacin) for 1 month, then come back to the lab to have your PSA checked again. I sent the prescription to your pharmacy. I entered the lab order for you. You do not need to fast.  [/shorthand][shorthand name="psahigher"]Your prostate cancer screening test (PSA) was higher than it was last time. It rose from ___ to ___. I recommend that you see a urologist.[/shorthand][shorthand name="psalower"]Your prostate cancer screening test (PSA) was lower than it was last time. It dropped from ___ to ___.[/shorthand][shorthand name="psaundetectable"]Your prostate cancer screening test (PSA) was undetectable.[/shorthand][shorthand name="pt"]patient[/shorthand][shorthand name="pth"]Your parathyroid hormone level was normal. This is a hormone that helps keep calcium in your bones.[/shorthand][shorthand name="pthhigh"]Your parathyroid hormone level is higher than normal. This is a hormone that helps keep calcium in your bones.[/shorthand][shorthand name="pthlow"]Your parathyroid hormone level was low. This is a hormone that helps keep calcium in your bones.[/shorthand][shorthand name="pthy"]pathophysiology[/shorthand][shorthand name="ptptt"]Your blood clotting test shows that your blood clots normally.[/shorthand][shorthand name="pvdarterialdopplerpos"]Your leg artery ultrasound showed moderate narrowing (plaque) in your leg arteries in both legs. Walking, controlling your blood pressure, and controlling your cholesterol will help keep the leg arteries open. I also recommend you take aspirin 81 mg 1 pill once a day (if you are not allergic to aspirin).[/shorthand][shorthand name="pvdriskfactors"]Continue to control risk factors including elevated blood pressure, elevated cholesterol, and/or elevated blood sugar. Continue daily antiplatelet therapy.[/shorthand][shorthand name="pvdsuspect"]Patient is at risk for PVD due to age 50-64 with at least 1 ACC/AHA risk factor (tobacco use, hypertension, diabetes mellitus, hyperlipidemia) OR is age 65+. Will do Quantaflo at next visit.[/shorthand][shorthand name="qhcg"]quantitative hcg[/shorthand][shorthand name="qs "]questions[/shorthand][shorthand name="quantiferongold"]Your QuantiFERON gold test (Tuberculosis test) was negative (normal).[/shorthand][shorthand name="rba"]Risks, benefits, and alternatives of the procedure were explained to the patient. Consent was signed. All questions were answered.[/shorthand][shorthand name="rbp"]Advised to go to the emergency room for any recurrent rectal bleeding with dizziness, abdominal pain, or other new or worsening concerns. [/shorthand][shorthand name="recalleukocyte"]There were now white blood cells in your stool. This is a normal result.[/shorthand][shorthand name="rech"]recheck [/shorthand][shorthand name="referral"]Once your referral is approved by your insurance company, we will contact you by mail or by phone with the information you need to make an appointment. Contact us if you have not heard anything in 2 weeks.[/shorthand][shorthand name="refill"]Refill sent to pharmacy.[/shorthand][shorthand name="reninaldosterone"]You have normal levels of the renin and aldosterone (hormones that help your kidneys control your blood pressure).[/shorthand][shorthand name="res"]reschedule[/shorthand][shorthand name="retic"]Your reticulocyte count (how many new red blood cells you body is making) is normal.[/shorthand][shorthand name="rf"]Your test for rheumatoid arthritis (rheumatoid factor) was negative (normal).[/shorthand][shorthand name="rice"]Rest the affected limb. Put ice on the affected limb for 15 minutes every 1-2 hours as needed for pain and swelling. Wear the recommended compression device as instructed. Elevate the limb when not using it. Take ibuprofen (Advil/Motrin), naproxen (Aleve), or acetaminophen (Tylenol) as needed for pain.[/shorthand][shorthand name="rlq "]right lower quadrant[/shorthand][shorthand name="rml"]right more than left[/shorthand][shorthand name="ro"]rule out[/shorthand][shorthand name="roi"]Please fill out a release of information form so we can request records from your previous doctor.[/shorthand][shorthand name="rom"]range of motion[/shorthand][shorthand name="rowb"]the risks outweigh the benefits[/shorthand][shorthand name="rpr"]Your blood test for syphilis (a sexually transmitted infection) was negative. You do not have syphilis.[/shorthand][shorthand name="rr"]records release[/shorthand][shorthand name="rsi"]repetitive strain injury[/shorthand][shorthand name="rtc"]return to the office[/shorthand][shorthand name="rtc1monptinst"]Come back to see me in 1 month or sooner if needed.[/shorthand][shorthand name="rtc1wkptinst"]Come back to see me in 1 week or sooner if needed.[/shorthand][shorthand name="rtc1yrptinstCPE"]Come back to see me in 1 year for your next annual physical. Contact us sooner if anything comes up before then.[/shorthand][shorthand name="rtc23wkptinst"]Come back to see me in 2-3 weeks or sooner if needed.[/shorthand][shorthand name="rtc2monptinst"]Come back to the clinic in 2 months.[/shorthand][shorthand name="rtc3monptinst"]Come back to see me in 3 months or sooner if needed.[/shorthand][shorthand name="rtc4mon"]Come back to see me in 4 months or sooner if needed.[/shorthand][shorthand name="rtc6monptins"]Come back to see me in 6 months or sooner if needed.[/shorthand][shorthand name="rtcawv"]Come back in ____ months for your Medicare Annual Wellness Visit.[/shorthand][shorthand name="rts "]return to school[/shorthand][shorthand name="rtw"]return to work[/shorthand][shorthand name="ruq"]right upper quadrant[/shorthand][shorthand name="rx"]prescription[/shorthand][shorthand name="samemeds"]Keep taking your other medicines the same way you are now.[/shorthand][shorthand name="screeningstopage75"]Patient's age >75 with no other risk factors, will stop routine screening.[/shorthand][shorthand name="screeninguptodate"]Cancer screening is up to date.[/shorthand][shorthand name="screenutd"]Screening up to date.[/shorthand][shorthand name="se"]side effects[/shorthand][shorthand name="seehpiros"]See HPI for further Review of Systems.[/shorthand][shorthand name="senilepurpura"]Wear long sleeves and long pants to protect your legs. Wear sunscreen on exposed arms and legs. Use moisturizing lotion on your arms daily.[/shorthand][shorthand name="shd"]Sleep hygiene reviewed including early exercise, avoidance of daytime naps, no stimulants such as caffeine beyond early afternoon, availability of sleep therapy modules, and role, effectiveness, and side effects of sleeping pills. [/shorthand][shorthand name="sinusitis"]You have a sinus infection.
Take the antibiotic you were prescribed until it is gone.
Take Mucinex DM or Robitussin DM as needed for cough and congestion.
You can also try Flonase Allergy 2 sprays to each nostril once a day for congestion.
You can also try salt water nose spray for stuffy nose.
If you do not have high blood pressure or heart problems, you can try Sudafed or similar decongestants for congestion.
You can take Claritin or Zyrtec as needed for drainage.
Take over-the-counter acetaminophen or ibuprofen as needed for pain or fever.
You can try throat lozenges or salt water gargles for any sore throat.
Your symptoms may take 7-10 days to go away.
Drink lots of fluids. Get plenty of rest.
Contact us if you have worsening symptoms such as high fever (102F), shortness of breath, inability to keep liquids and solids down, or other worsening symptoms. Contact us if your symptoms fail to improve after 10 days.
If your symptoms get worse after the clinic is closed, you can call our office to reach the on-call doctor.[/shorthand][shorthand name="sjogren"]Your blood tests for Sjogren's disease, a type of autoimmune disease, were negative (normal).[/shorthand][shorthand name="slidingscaleinsulin"]Check your blood sugar before each meal and before bedtime.
If your blood sugar is less than 200, do not take short-acting insulin (Humalog/Novolog).
If your blood sugar is 200-250, take 2 units of short-acting insulin.
If your blood sugar is 251-300, take 4 units of short-acting insulin.
If your blood sugar is 301-350, take 6 units of short-acting insulin.
If your blood sugar is 351-400, take 8 units of short-acting insulin.
If your blood sugar is 401 or higher, take 10 units of short-acting insulin.[/shorthand][shorthand name="slr"]straight leg raise[/shorthand][shorthand name="smokingcessationadvice"]I recommend that you quit smoking. I can help you get off tobacco when you are ready to stop.[/shorthand][shorthand name="sodiumurine"]You have a normal amount of salt (sodium) in your urine.[/shorthand][shorthand name="specialistcare"]This chronic condition is monitored and treated by a specialist listed in the Care Team section of the chart.[/shorthand][shorthand name="spirometrynormal"]Your lung tests (spirometry) do not show COPD (also called emphysema or chronic bronchitis).[/shorthand][shorthand name="srom"]spontaneous rupture of membranes[/shorthand][shorthand name="SSRIses "]Side effects and use reviewed, including nausea or stomach upset, insomnia or fatigue, headaches, and sexual side effects, and patient advised to notify ASAP and stop pill for any concerning untoward effects.[/shorthand][shorthand name="stable"]Condition is stable. Continue current treatment plan.[/shorthand][shorthand name="stableDM"]A1C is below goal of <7.0%. Condition is stable. Continue current treatment plan.[/shorthand][shorthand name="stablespecialist"]Condition is stable. Continue current treatment plan per specialist physician who is managing this condition.[/shorthand][shorthand name="statdm"]Discussion of new reports of some statins leading to hyperglycemia or worsening of diabetes. In weighing pros and cons, the patient elects to stay on current statin. [/shorthand][shorthand name="statinses"]Statin side effects discussed, including initial fatigue, myalgias, rare liver damage, and possible memory loss.[/shorthand][shorthand name="steroidses "]Short-term side effects of steroids reviewed, including gastritis, insomnia, moodiness, and potential for increase in blood pressure or sugar.[/shorthand][shorthand name="sthg"]strengthening[/shorthand][shorthand name="stoolcx"]Your stool culture did not show any evidence of common intestinal bacterial infections.[/shorthand][shorthand name="stoolfecalleuk"]Your stool did not have any white blood cells in it. White blood cells in the stool are a sign of inflammation in the colon, or large intestine.[/shorthand][shorthand name="stoolop"]Your test for parasite infections in your intestines did not show evidence of common parasite infections.[/shorthand][shorthand name="sua"]sulfonylurea[/shorthand][shorthand name="sugarlog"]Check your blood sugar each morning before you eat breakfast. Write it down and bring that blood sugar log to your next appointment. Notify me if your blood sugar stays over 140 in the morning.[/shorthand][shorthand name="surgrisk"]Based on Lee's Revised Cardiac Risk Index, patient has a ____ % risk of cardiovascular complications from the planned surgery. This risk is based on chronic conditions that are currently well controlled. Patient may proceed with surgery.[/shorthand][shorthand name="sutures"]You can wash the area where you have the stitches tomorrow. Rinse the area with the stitches gently, but do not scrub that area. Contact us if you have any bleeding, swelling, redness, increased pain, or fever. Come back in 7-10 days to have the sutures removed.[/shorthand][shorthand name="sx"]symptoms[/shorthand][shorthand name="syphilis"]Your test for syphilis was negative. You do not have evidence of syphilis infection in you body.[/shorthand][shorthand name="sz"]seizure[/shorthand][shorthand name="t3free"]Your free T3 level (one of the 2 active types of thyroid hormone) is normal.[/shorthand][shorthand name="t3high"]Your T3 level (one of the 2 active types of thyroid hormone) is higher than it should be. I think you have hyperthyroidism.[/shorthand][shorthand name="t3total"]Your total T3 level (one of the 2 active types of thyroid hormone) is normal.[/shorthand][shorthand name="t4free"]Your free T4 level (one of the 2 active types of thyroid hormone) is normal.[/shorthand][shorthand name="t4freelow"]Your free T4 level (one of the 2 active types of thyroid hormone) is low. This means that your thyroid gland is not making enough of this hormone.[/shorthand][shorthand name="t4high"]Your T4 level (one of the 2 active types of thyroid hormone) is higher than it should be. I think you have hyperthyroidism.[/shorthand][shorthand name="t4total"]Your total T4 level (one of the 2 active types of thyroid hormone) is normal.[/shorthand][shorthand name="testosteronehigh"]Your total testosterone level (the total amount in your body) is higher than it should be.
Your free testosterone (the amount of testosterone circulating in your bloodstream) is higher than it should be.[/shorthand][shorthand name="testosteronelow"]Your total testosterone level (the total amount in your body) is lower than it should be.
Your free testosterone (the amount of testosterone circulating in your bloodstream) is lower than it should be.[/shorthand][shorthand name="testosteronenormal"]Your total testosterone level (the total amount in your body) is normal.
Your free testosterone (the amount of testosterone circulating in your bloodstream) is normal.[/shorthand][shorthand name="testresult"]Results discussed with patient at time of visit.[/shorthand][shorthand name="thiamine"]Your thiamine (vitamin B1) level was normal.[/shorthand][shorthand name="thyroglobulinab"]Your thyroglobulin antibody test (test for thyroid inflammation called thyroiditis) was normal (negative).[/shorthand][shorthand name="thyroidperoxidaseab"]Your thyroid peroxidase antibody test (test for thyroid inflammation called thyroiditis) was normal (negative).[/shorthand][shorthand name="tmj "]temporomandibular joint[/shorthand][shorthand name="tobed"]Patient counseled to quit smoking. Patient advised that smoking worsens his/her underlying chronic illnesses.[/shorthand][shorthand name="travel"]To find out what medicines and vaccines you need for your trip, go to the CDC Travelers' Health website: www.cdc.gov/travel. Type the name of the country or countries you are visiting. Please contact us at least a month before your trip. Many travel vaccines have to be ordered, or must be given a month before your trip. Bring any medicines in their original bottles.
If you have internet access while you travel, you can use our Patient Portal to contact us if you have any questions.[/shorthand][shorthand name="troponinI"]Your troponin I (test for heart muscle damage from a heart attack) was normal (negative).[/shorthand][shorthand name="tsh"]Your thyroid test was normal.[/shorthand][shorthand name="tshatgoal"]Your thyroid test was normal. Keep taking the same dose of thyroid medicine you are taking now.[/shorthand][shorthand name="tshhigh"]Your thyroid test was higher than it should be. This means that your body does not have enough thyroid hormone. I will send a prescription for thyroid medicine to your pharmacy. Start taking this medicine now.[/shorthand][shorthand name="tshlow"]Your thyroid test is lower than it should be. This means that your dose of thyroid medicine is too high. I think you could take a lower dose of thyroid hormone.[/shorthand][shorthand name="tx"]treatment[/shorthand][shorthand name="uc"]urgent care[/shorthand][shorthand name="ucx"]Your urine culture did not show signs of a urinary tract infection.[/shorthand][shorthand name="ucxpositive"]Your urine culture did show a urinary tract infection. Keep taking the antibiotic that I prescribed.[/shorthand][shorthand name="uri"]You have a viral upper respiratory infection.
Take Mucinex DM or Robitussin DM as needed for cough and congestion.
You can also try Flonase Allergy 2 sprays to each nostril once a day for congestion.
You can also try salt water nose spray for stuffy nose.
If you do not have high blood pressure or heart problems, you can try Sudafed or similar decongestants for congestion.
You can take Claritin or Zyrtec as needed for drainage.
Take over-the-counter acetaminophen or ibuprofen as needed for pain or fever.
You can try throat lozenges or salt water gargles for any sore throat. 
Your symptoms may take 7-10 days to go away.
Drink lots of fluids. Get plenty of rest.
Contact us if you have worsening symptoms such as high fever (102F), shortness of breath, inability to keep liquids and solids down, or other worsening symptoms. Contact us if your symptoms fail to improve after 10 days. 
If your symptoms get worse after the clinic is closed, you can call our office to reach the on-call doctor.[/shorthand][shorthand name="uric"]Your uric acid (gout test) was normal.[/shorthand][shorthand name="urichigh"]Your uric acid (gout test) was higher than normal.[/shorthand][shorthand name="uried"]Over-the-counter measures and efficacy discussed, notify if not improving or worsening or new symptoms such as fever or shortness of breath or emesis. Education on course and pathophysiology, as well as lack of efficacy of antibiotics.[/shorthand][shorthand name="urinalysis"]Your urine test (urinalysis) was normal. It did not show any signs of a urine infection.[/shorthand][shorthand name="urinalysisreflexnegative"]Your urine test (urinalysis) showed a possible urinary tract infection, but the urine culture did not confirm a urinary tract infection.[/shorthand][shorthand name="urinesodium"]The amount of sodium (salt) in your urine is normal.[/shorthand][shorthand name="urticaria"]Finish steroid dose pack.
Take Zyrtec 10mg 1 pill each night until welts are gone.
Take Zantac 150mg 1 pill twice a day until welts are gone.
Let me know if the welts do not gradually go away over the next 1-2 weeks.
You can put hydrocortisone cream (buy this over the counter) on the welts as needed to help with the itching.[/shorthand][shorthand name="usabdomen"]The ultrasound of your abdomen showed that your liver, spleen, kidneys, pancreas, and aorta (large artery in your abdomen) was normal.[/shorthand][shorthand name="usaorta"]The ultrasound of your aorta (main artery that goes from your heart to the rest of your body) shows that your aorta is normal.[/shorthand][shorthand name="usliver"]The ultrasound of your liver and gallbladder was normal.[/shorthand][shorthand name="uspelvis"]The ultrasound of your pelvis showed that your uterus and ovaries look normal.[/shorthand][shorthand name="usruq"]The ultrasound of your liver showed that your liver looked normal.[/shorthand][shorthand name="uss"]ultrasound[/shorthand][shorthand name="ustestes"]The ultrasound of your testicles and scrotum was normal.[/shorthand][shorthand name="utd "]up to date[/shorthand][shorthand name="uti"]Wipe from back to front after you urinate.
Drink plenty of fluids. You can try cranberry juice to see if that helps.
Take acetaminophen (Tylenol) or ibuprofen (Advil) as needed for pain.
Contact us if your symptoms do not get better over the next 7 days or if they get worse.[/shorthand][shorthand name="utitx"]Your urine culture showed a urinary tract infection. I sent a prescription for an antibiotic to your pharmacy.[/shorthand][shorthand name="vaccinerefusal"]Patient declined vaccine after we discussed risks and benefits of vaccination.[/shorthand][shorthand name="vanderbilt"]NICHQ Vanderbilt Assessment Scale: Inattention: _ /9, Hyperactivity _ /9; Oppositional: _ /8, Conduct _ /14, Anxiety _ /7[/shorthand][shorthand name="varicocele"]Your testicle and scrotum ultrasound  showed some enlarged veins near the left testicle. This is called a varicocele. It is like varicose veins in your scrotum. It is harmless. It only needs to be removed if it is painful.[/shorthand][shorthand name="varicoseveins"]I recommend that you buy compression stockings from the pharmacy and where them daily.  Elevate your legs when you do not have to be on your feet. Let me know if you start having pain in your legs.[/shorthand][shorthand name="venousdopplerus"]The ultrasound test of the veins of your legs did not show any blood clots.[/shorthand][shorthand name="vgep"]Notify us ASAP or go to emergency room for blood in stool, dizziness, fevers, or other new concerns.[/shorthand][shorthand name="viralgi"]Try fluids such as water, juice, soup, and clear sodas.
Eat bland foods such as bananas, rice, apple sauce, and toast. Avoid greasy foods and fried foods. Minimize dairy foods until you feels better. Illness may last up to 7 days.
Call or return to clinic if you cannot take liquid and food by mouth, cannot make urine, are lethargic, have a fever that does not resolve with acetaminophen or ibuprofen, or your symptoms have not improved after 7 days.[/shorthand][shorthand name="vitd"]You have a normal amount of vitamin D. Vitamin D helps your body keep your bones strong.[/shorthand][shorthand name="vitdlow"]Your body has less vitamin D than normal. Vitamin D helps your body keep your bones strong. I want you to start taking vitamin D ___,000 units 1 pill once a day.[/shorthand][shorthand name="wd"]would[/shorthand][shorthand name="weightlossplans"]Go to this website to find strategies for successful weight loss: https://www.nutrition.gov/weight-management/strategies-success
Here is a basic handout to help you start losing weight: https://www.nutrition.gov/weight-management/strategies-success/interested-losing-weight
This website tells you how to find out what a healthy weight is for you: https://www.nhlbi.nih.gov/health/educational/lose_wt/index.htm
This website helps you customize an eating plan to your height, weight, and weight loss goal: https://www.choosemyplate.gov/MyPlate-Daily-Checklist[/shorthand][shorthand name="weightrestriction10lbs"]Do not lift more than 10 pounds for 1 month.[/shorthand][shorthand name="wi"]within[/shorthand][shorthand name="wo"]without[/shorthand][shorthand name="wound"]Each day rinse your leg wound with soapy water, then pat the area dry.
Put Triple Antibiotic Ointment on the wound, then cover it with petrolatum soaked gauze. Cover that with an absorbent gauze bandage.
Contact us if you get increased pain, swelling, bloody or yellow/green drainage[/shorthand][shorthand name="wrd"]Warned re: potential for drowsiness and not to drive or other activities that require alertness after taking. [/shorthand][shorthand name="wu"]work up[/shorthand][shorthand name="ww"]Weight Watchers[/shorthand][shorthand name="yo"]year old[/shorthand]

[textarea]This is an example of SOAPnote Shorthand.  To see it working type '5210' in this box and then hit the space key[/textarea]
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references: 
 [link url="https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/starter-list-macros.html" memo="#1"] A starter list of EHR macros to save time on documentation. Family Practice Management. https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/starter-list-macros.html Published August 29, 2022. Accessed October 21, 2023.[/conditional]