Dot Phrases (Alphabetized) (Non-Condensed)
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A
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# ADHD Discussed behavioral therapy.
Exercise after school.
Healthy diet.
Decrease screen time <2 hrs.
Sleep hygiene.
Mindful meditation.
Consider IEP. Parent will ask at school.
Recommended community resources.
Recommended book for parent education (The nurtured heart approach).
Gave Parent/Teacher Vanderbilt assessment. Will bring back at next visit. Will consider stimulant tx if dx confirmed and no improvement w/ behavioral tx.
vadhd#-adult
# ADHD Stable.
Continue behavioral therapy.
Continue current stimulant dose.
vadhd-f/u
ADHD Patient reports good control of symptoms of inattention, impulsivity, and restlessness, On stimulant.
Compliant with meds.
Denies any side effects.
Enables pt to have a functional professional life.
,.adhd-letter
Dear principal,
The above named student was diagnosed with attention deficit hyperactivity disorder (ADHD). By this office on _ and was last seen on The diagnosis was based on patient, family and teacher reports, physical examination, diagnostic criteria, standardized questionnaires, and other testing. Medical and behavioral treatment and monitoring will be ongoing.
Although our evaluation focused on ADHD we also discussed with the parents learning and behavior disorders, school-based educational/ behavioral assessments, section 504, IDEA, and psychometric academic/ achievement testing. Information given to the parents included “educational rights for children with ADHD” at http:// www.help4adhd.org.
This medical report documents that a diagnosis of ADHD, a neurobiological disorder which may limit learning thereby qualifying the student for appropriate academic or behavioral accommodations. Modifications recommended by section 504 of the rehabilitation act of 1973 include “physical arrangement of room, lesson preparation, assignments/worksheets, transportation, test-taking, organization, behaviors, medications, discipline or other as specified.”
This letter is a formal request from the parents and the physician for further psychological and academic assessments of this student. A copy of this notification has been given to the parent for their use and is on file in our medical records department.
Thank you for this opportunity to work cooperatively with you and my patient’s family.
Sincerely,
,.adhd-letter-adult
To Whom It May Concern,
The above named student was diagnosed with attention deficit hyperactivity disorder (ADHD). By this office on _ and was last seen on The diagnosis was based on patient and family reports, physical examination, diagnostic criteria, standardized questionnaires, and other testing. Medical and behavioral treatment and monitoring will be ongoing.
Although our evaluation focused on ADHD we also discussed with the patient learning and behavior disorders, school-based educational/ behavioral assessments, section 504, IDEA, and psychometric academic/ achievement testing. Information given to the parents included “educational rights for people with ADHD” at http://www.help4adhd.org.
This medical report documents that a diagnosis of ADHD, a neurobiological disorder which may limit learning thereby qualifying the student for appropriate academic or behavioral accommodations. Modifications recommended by section 504 of the rehabilitation act of 1973 include “physical arrangement of room, lesson preparation, assignments/worksheets, transportation, test-taking, organization, behaviors, medications, discipline or other as specified.”
Thank you for this opportunity to work cooperatively with you and this patient.
Sincerely,
anxiety
Anxiety
Experiencing physical and emotional stress.
Complains of life stressors, feels stressed about _.
Excessive worrying about _.
Symptoms have been present for >6 months. Impairing sleep and concentration.
Complains of fatigue and irritability.
No CP, SOB, GI symptoms. No history of physical or emotional trauma or death of a loved one.
Does not report panic attacks.
Denies any use of drugs, excessive caffeine or alcohol.
No thyroid disease.
No Family Hx of psychiatric conditions.
Endorses depression.
Denies suicidal ideation.
Denies any manic or hypomanic episodes.
Denies any visual or auditory hallucinations.
anxiety#
# ADHD, adult Adult ADHD Self-Report Scale (ASRS-vl.l) Symptom Checklist highly consistent with diagnosis.
Discussed behavioral therapy.
Exercise.
Healthy diet.
Decrease screen time <2 hrs.
Sleep hygiene.
Mindful meditation.
Will consider stimulant tx if dx confirmed and no improvement w/ behavioral tx.
,.adhd#-f/u
# AOCD
Asymptomatic.
Monitor.
Treatment of underlying disease.
,.lymphadenopathy
Pt c/o lump.
Located on the neck, right, x wks.
Denies any recent infections or URI symptoms.
Denies occupational exposures.
Does not have pets.
No recent travel or high-risk behaviors.
Denies any fever, night sweats, or unexplained weight loss.
,.lymphadenopathy#
# Abnormal vaginal bleeding
Pregnancy was ruled-out.
Sent for CBC and TSH.
Sent for transvaginal US.
Consider endometrial biopsy.
Trial of OCPs and NSAIDs.
---------
B
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,.bartholin-cyst
Pt c/o a pimple/vulvar mass x days.
Reports vulval pressure or fullness.
Some pain with walking/sitting. + dyspareunia.
No fevers or chills.
No spontaneous rupture.
,.bartholin-cyst #large
# Abscess, S/p incision and drainage.
The patient tolerated the procedure well without complications.
Standard post-procedure care is explained and return precautions are give.
No antibiotic needed.
Return 1 week for packing replacement and wound care.
Return precautions discussed with patient, including excessive bleeding, fever, worsening of purulent discharge.
abscess*
10060
,.abscess-PE
Erythematous abscess mass noted superficially on
Measuring about
Punctate central exudative drainage.
Surrounding erythema.
Area is tender and warm to touch.
Fluctuance palpated.
,.abscess-loop-proc
Abscess I&D
Informed verbal consent was obtained.
Risks (including recurrence, unaesthetic scar, failure to resolve), benefits, and alternatives were reviewed with patient.
The area was prepared and draped in the usual sterile manner.
Local anesthetic with 1% lidlocaine w/ epinephrine instilled using 30G needle.
Abscess I&D'ed using Noll blade. Abscess was probed, and pus was drained.
Copious pus and caseous material removed.
Hemostats were introduced to break up loculations.
Cavity is irrigated with betadine.
A second incision, distal to the first one was made.
A loop drain was passed through one incision, brought out through the other, and tied to itself.
Covered with a gauze.
Bleeding was minimal.
Pt tolerated procedure well.
,.abscess-proc
Abscess I&D Informed verbal consent was obtained.
Risks (including recurrence, unaesthetic scar, failure to resolve), benefits, and alternatives were reviewed with patient.
The area was prepared and draped in the usual sterile manner.
Local anesthetic with 1% lidlocaine w/ epinephrine instilled using 30G needle.
Abscess I&D'ed using Noll blade. Abscess was probed, and pus was drained.
Copious pus and caseous material removed.
Cavity is irrigated with betadine.
Hemostats were introduced to break up loculations.
Sterile packing placed in the incision. Wound dressed with dry, sterile dressing.
Pt tolerated procedure well.
Bleeding was minimal.
,.anoscope-PE
Anoscopy revealed small internal hemorrhoid on right anterior segment.
,.anoscopy*
46600
,.debridement-wound-proc
Wound debridement Location: _ Size: _ cm (_ sq cm) Method of debridement:
Excisional - devitalized tissue was removed with a 10 blade scalpel.
241 statnote dot phrases - primary care phrase library
Nonexcisional - irrigation with normal saline after using peroxide to clean blood.
Depth of debridement: skin and subcutaneous tissue (epidermis/dermis). Debridement within wound margins.
Wound dressing applied.
Left to heal by secondary intention.
,. debridement-wound*< 20sq-cm
97597
,.debridement-wound*ea-add20sq-cm
97598
dental-abscess
Pt c/o dental pain and swelling of gum.
Noted a pocket of fluid on gum.
No spontaneous drainage, no bleeding.
No fevers or chills.
Attempted to get dentist appointment but is unavailable until next week.
dental-abscess#
# Achilles tendinosis Activity modification.
Ice when symptomatic.
Prn NSAIDs.
Achilles tendon taping with ankle strapping for support done in clinic.
,.achilles-tendinitis-PE
Right achilles tendon with localized tenderness proximal to its insertion. Increased thickness and tender nodule palpated. Negative Thompson test.
,.ankle-PE
Ankle Exam:
Right ankle examined.
No edema.
No TTP over the posterior or tip of medial/lateral malleoli, proximal 5th MT, or Navicular.
Neg squeeze test.
Full ROM.
Full overall Strength.
ATFL Intact on Anterior Drawer.
Deltoid Ligament Intact.
,.ankle-pain
Pt c/o ankle pain, right. Location: lateral.
Worsens with ambulation. No symptoms of instability. No injury.
No h/o surgery.
137 statnote dot phrases - primary care phrase library
,. ankle-pain-acute
Pt c/o ankle pain, right.
Sustained injury days ago.
Felt immediate pain on the lateral side. Was able to ambulate after incident. Denies h/o previous ankle injuries. Has used NSAlDs with minor relief.
ankle-sprain#
# Acne BPO wash. Clindamycin gel. Topical retinoid.
,.acne-PE
Open/closed comedones and erythematous papules and pustules. No nodules/cysts. No pitted/hypertrophic scars. Face/upper trunk involved.
acne-baby
Multiple inflammatory papules, small pustules/closed comedones at cheeks w/ some erythematous background.
,.acne-sx-comedo*
10040
,.ak-hpi
Patient complains of scaly lesion on _.
Present for many months.
C/o some itching.
No personal or family history of skin cancer. + sun exposure. Does not use photoprotection.
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,.ak#
# Actinic keratosis Cryotherapy done. Discussed photoprotection.
Vak-PE
Scaly and rough papule with ill-defined borders on
alopecia-female
Alopecia Complains of hair loss for the last few months.
Endorses family history of baldness.
Reports diffuse thinning of the central scalp with preservation of frontotemporal hairline.
alopecia-male
Alopecia Complains of hair loss for the last few months. Endorses family history of baldness.
Reports gradual receding of frontal hairline and crown.
,. alop ecia# female
# Acute otitis media Likely viral Pt is afebrile, mild discomfort Tylenol prn pain or fever Return if fever, otorrhea, worsening or no improvement after 48-72 hrs
j.otitis-externa#
# Acute otitis media Likely viral Pt is afebrile, mild discomfort Tylenol prn pain or fever Return if fever, otorrhea, worsening or no improvement after 48-72 hrs
,.otitis-externa#
# Acute otitis media Tylenol prn pain or fever Rx amoxicillin 500 mg PO tid x 7d Return if no improvement after 48-72 hrs
81 statnote dot phrases - primary care phrase library
,.otitis#viral
# Acute otitis media Tylenol prn pain or fever Rx amoxicillin 500 mg PO tid x 7d Return if no improvement after 48-72 hrs
81 statnote dot phrases - primary care phrase library
,.otitis#viral
# Acute vestibular neuritis Supportive care.
Patient education and reassurance.
,.dizziness-PE
Ears: Bilateral TMs, clear. Normal hearing.
Eyes: PERRLA. EOMI. No nystagmus.
Cardiovascular: RRR, NL S1/S2, no murmurs.
Neurologic: CN 2-12 WNL. No dysmetria. No ataxia. Negative Romberg’s. Negative Dix-Hallpike test.
Negative Head Impulse test.
No Nystagmus.
Negative Test of Skew.
headache
Pt c/o headache.
Sudden/gradual onset _days ago. worsening. Located: No radiation.
Described as throbbing, pounding, dull, sharp. Pain is intermittent/constant.
Lasts for hours.
Does not awake pt from sleep.
Relieved with _ Exacerbates with _certain foods.
No aura.
No photophobia, no phonophobia.
No nausea, no vomiting.
Denies any recent emotional stress.
No previous similar episodes.
No h/o trauma.
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Denies h/o migraines, cluster headaches, tension headaches. Denies chronic use of NSAIDs or recent d/c of caffeine. Does not smoke, denies any drug use.
No recent URI symptoms.
LMP: wks ago.
hiccups
Pt c/o persistent hiccups.
Started days ago.
Denies excessive alcohol or food consumption.
vhiccups#
# Advance care planning Explained and discussed planning of medical care in the event of loss of decision-making abilities.
Discussed and filled-out Advance Healthcare Directive form.
Discussed and filled-out POLST form.
Face-to-face voluntary discussion for 16 minutes were spent during this encounter.
Present for discussion: patient only.
,.chronic-bzd
Chronic use of benzodiazepines Indication: _ Hours able to sleep w/ med: _ Hours able to sleep w/o med: _ Symptoms reduction w/ med: _% Taking medication as directed.
Including: alprazolam Psychosomatic symptoms including anxiety, depression and insomnia are being treated. statnote dot phrases - primary care phrase library
Denies any side effects from medication including sedation. Medications are not interfering with ADLs.
Addiction 4C: Denies craving, compulsive behavior, lack of self-control. Denies negative consequences as a result of using controlled substances. Not taking any opioids.
Does not mix with alcohol.
,.chronic-bzd#
# Alcohol use disorder Intervention: Counseled on cessation/cutting down - 15 min. Patient shows interest.
Feedback about patient’s alcohol use.
222 statnote dot phrases - primary care phrase library
Psychosocial interventions: Discussed non-pharmacologic tx including CBT, psychotherapy, AA, addiction programs, or other support groups. Consider pharmacotherapy to prevent relapse and support abstinence.
,.etoh/substance-counsel*
99408
, .grief#
# Allergic conjunctivitis Instructed not to rub the eyes, d/c contact lens use, apply cold compresses.
75 statnote dot phrases - primary care phrase library
Liberal use of refrigerated artificial tears.
Chronic - mast cell stabilizer (cromolyn 4% 2 gtt q6h) + antihistamine.
ear-lavage
Ear lavage _Right ear irrigated with lukewarm water, hydrogen peroxide, and OtoClear. Large piece of brown cerumen extracted with ear curette.
TM: wnl. Pt tolerated procedure well.
ear-lavage*
69210
,. ear-lavage*F OB
69200
,.ear-lavage-FOB-removal
Ear foreign body removal Under direct visualization, foreign body from the _ external auditory canal was removed using alligator forceps.
Pt tolerated procedure well.
,.epistaxis
Pt c/o bleeding from the nose.
Recurrent with several episodes in the last few days. No h/o bleeding disorders.
Not on anticoagulation.
Denies easy bruising or gum bleeding.
76 statnote dot phrases - primary care phrase library
,.epistaxis#
# Allergic conjunctivitis Instructed not to rub the eyes, d/c contact lens use, apply cold compresses. Liberal use of refrigerated artificial tears.
Acute - Short-term tx (2 wk) of opht antihistamine.
(naphazoline, ketotifen, or olopatadine 0.2% 1 gtt qd).
,.conjunctivitis-allergic#chronic
# Allergic rhinitis Intermittent mild symptoms.
Trial of flonase, oral antihistamine, and allergen avoidance.
Consider leukotriene receptor if symptoms become persistent/moderate.
cataracts
Pt c/o gradual decrease in vision. Endorses blurred or cloudy vision. Glare when driving at night.
73 statnote dot phrases - primary care phrase library
cataracts#
# Alopecia, androgenic Negative hair-pull test.
Lab w/u: TSH, iron panel, CBC, fee testosterone, and RPR. Trial of minoxidil, topical.
Consider finasteride if not improving.
,. alop ecia-area ta
Pt c/o patch of hair loss on scalp.
Reports some emotional stress lately.
No itching or burning sensation in the area. No h/o atopic dermatitis, vitiligo or thyroid ds.
,.alopecia-areata-PE
Round, patchy areas of nonscarring hair loss on occipital area measuring 3 x 3 cm. Also affecting right cheek lxl cm. No hypopigmentation areas. Exclamation point Hairs observed.
,.alopecia-areata-inj*
11900
,.alopecia-areata-inj
Intralesional steroid injection.
After discussion of risks and benefits of corticosteroid injection, including but not limited to infection, bleeding, discomfort with injection, skin atrophy or color changes, injury to surrounding structures, elevated blood
41 statnote dot phrases - primary care phrase library
sugar, and possibility of no improvement, patient gave verbal and written consent.
Area was cleaned with alcohol.
1 cc of Kenalog 4 mg/mL mix with plain 1% lidocaine were injected on _left occipital area.
alopecia- female-PE
Marked reduction in terminal hair density present on bitemporal and occipital area.
,.alopecia-male-PE
Marked reduction in terminal hair density present on the frontal hairline and vertex.
,.bedbug-PE
Urticaria-like papules and vesicles on exposed areas (neck, arms, hands), linear configuration.
bedbug#
# Alopecia, female pattern Negative hair-pull test.
Lab w/u: TSH, iron panel, CBC, fee testosterone, and RPR. Trial of minoxidil, topical.
40
! statnote dot phrases - primary care phrase library
Consider spironolactone if not improving.
,.alopecia#male
# Alzheimer dementia Stable. Continue supportive care. Caregiver in place.
Safe environment at home. Cholinesterase inhibitors.
No depression.
No anxiety.
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No insomnia.
bell-palsy
Pt c/o sudden onset left facial weakness. Normal sensation.
C/o dry eye on same side.
No fever/chills, rash, myalgia/arthralgias. No previous similar episodes.
bell-palsy#
# Anemia, iron deficiency Continue iron supplementation/iron-rich diet. Asymptomatic.
anemia# AOCD
# Ankle sprain, right Continue conservative management. Weight-bearing.
Pain control.
ROM and strength exercises.
Ankle brace.
,.ankle-sprain#acute
# Ankle sprain, right Followed Ottawa rules and pt was sent for x-ray.
X-ray was unremarkable, with no fracture.
Limited wt bearing.
Early mobilization.
Range-of-motion exercises.
Ice.
Ankle brace.
Elevation.
Pain control.
RTC if condition worsening or not improving in a week.
,.back-PE-low
Lower back: no obvious deformities.
138 statnote dot phrases - primary care phrase library
,.hearing-loss#presbycusis
# Anxiety
Start Continue SSRls.
Recommended Cognitive Behavioral Therapy.
Reviewed relaxation techniques.
Recommended mindfulness meditation and exercise. Sleep hygiene. Insight-oriented psychotherapy given for 16 minutes exclusively. Psychoeducation: encouraged personality growth and development through coping techniques and problem-solving skills.
,.anxiety-f/u
Anxiety Compliant with SSR1. no side effects.
Not attending psychotherapy.
Experiencing less physical and emotional stress. Exercising.
Sleeping more than 6 hrs.
Does not report panic attacks.
No CP, SOB, GI symptoms or palpitations. Denies depression or suicidal ideation.
autism
Autism Reports no language delay.
No verbal or nonverbal communication impairment. No social impairment.
218 statnote dot phrases - primary care phrase library
No repetitive behavior, no stereotyped interest. Pt has a routine for daily activities.
Requires family support.
Community support:
Doing well at school.
Does not have an Individual Education Program. No sleeping difficulties.
Denies anxiety' or depression.
,.autism#
# Aortic stenosis Asymptomatic.
Vmax < 4 m/s.
Mean pressure gradient < 40 mmHg.
Continue conservative management w/ BB, ACEi, diuretics. Optimal BP control.
Recent stress test. 2d echo done <1 yr ago.
No CAD, CHF. EF >50%.
,.cad-hpi
CAD Compliant with medical management and lifestyle changes. On ASA, BB, ACE inhibitor, stadn. Plavix.
Denies side effects from medications.
Denies chest pain or palpitations. Not using NTG.
No changes in exertion tolerance.
Patient does not smoke.
Not seen recently by cardiologist.
,.cad#
# Asplenia Menactra given.
Rx meningococcal B. Pneumovax given. Bactrim prn fever.
}.celiac-ds
Pt c/o abdominal discomfort, diarrhea and bloating. Symptoms seem to improve when following a gluten-free diet. No family hx of Celiac ds or IBD.
Denies any fatigue, wt loss, rashes.
,.celiac-ds#
# Asthma Well controlled.
Maintain current tx step.
Explained quick-relief vs controlled meds.
Reviewed inhaler/device technique.
Consider step down if well controlled for >3 mo. Spirometry done less than a year ago.
Reinforced self monitoring of symptoms and peak flow.
226 statnote dot phrases - primary care phrase library
asthma-exacerbation
Pt w/ asthma presents with SOB, productive cough and wheezing x days. Not responding to inhalers.
No fevers or chills.
No UR1 symptoms.
No sick contacts.
asthma-exercise
Asthma On pm albuterol.
SOB/wheezing only when exercising.
Otherwise no activity limits, no symptoms at night or when at rest.
asthma-exercise#
# Asthma, exercise induced Stable.
Continue albuterol prior to exertion.
,.copd
COPD Compliant with inhalers.
SOB only w/ strenuous exercise/hurrying @ level/walking slight hill. SOB w/ walking @ level; must make stops. Productive cough most days. No hospitalizations for exacerbations during the last year.
Not smoking.
,.copd#
# Atrial fibrillation Stable.
Rate controlled.
Continue anticoagulation. No changes in management.
,.as-hpi
Aortic stenosis Compliant with meds.
No exertional dyspnea, chest pain or syncope.
32 statnote dot phrases - primary care phrase library
# Atypical chest pain EKG w/o any acute ischemic findings. No risk factors.
Reassured pt.
Consider stress test if persistent.
,.hld-hpi
Hyperlipidemia Compliant with statin. No side effects. Following a low-cholesterol diet.
,.hld#
# Autism Verbal and cognitive capacity, close to normal.
# Autism Verbal and cognitive capacity, close to normal.
Monitor educational progress, seems to have appropriate education at this point.
Family support: referred to local support resources.
binge-eating
Binge eating Patient reports struggling with the amount of food eaten.
Reports lack of control and distress over eating.
These episodes occur more than once a week.
Patient reports low self-esteem and depression over the situation and inability to lose weight.
binge-eating#
# BPH Mild disease with no significant bother.
Watchful waiting.
Behavioral management (limit fluids, bladder training).
,.bxo#
# BPH Mild disease with no significant bother.
Watchful waiting.
Behavioral management (limit fluids, bladder training).
,.bxo#
# Balanitis Improve personal hygiene.
# Balanitis Improve personal hygiene.
Daily foreskin retraction.
Vinegar and water soaks.
Topical antifungal.
Consider low-potency steroid if not improving.
,.balanitis-PE
Uncircumcised penis, erythema on glans of penis and foreskin.
230
! statnote dot phrases - primary care phrase library
,.ckd-hpi
CKD Compliant with medications.
Denies peripheral edema, SOB, orthopnea.
Does not check weight at home. Did not notice weight gain. Patient is not being followed by nephrologist.
,.ckd#
# Balanitis xerotica obliterates Trial of 0.05% clobetasol ointment applied bid until improvement. Then apply 0.05% betamethasone ointment bid for 1 month. Very gradual taper off.
Discussed circumcision is curative for phimosis. Consider if no improvement.
,.bph-hpi
BPH On flomax.
No complains of frequency, nocturia, urgency, incomplete voiding. No incontinence.
,.bph#
# Balanitis xerotica obliterates Trial of 0.05% clobetasol ointment applied bid until improvement. Then apply 0.05% betamethasone ointment bid for 1 month. Very gradual taper off.
Discussed circumcision is curative for phimosis. Consider if no improvement.
,.bph-hpi
BPH On flomax.
No complains of frequency, nocturia, urgency, incomplete voiding. No incontinence.
,.bph#
# Balanitis xerotica obliterates Trial of 0.05^Tclobetasol ointment applied bid until improvement. Then apply 0.05% betamethasone ointment bid for 1 month. Very gradual taper off.
Discussed circumcision is curative for phimosis. Consider if no improvement.
231 statnote dot phrases - primary care phrase library
,.ckd-hpi
CKD Compliant with medications.
Denies peripheral edema, SOB, orthopnea.
Does not check weight at home. Did not notice weight gain. Patient is not being followed by nephrologist.
,.ckd#
# Balanitis xerotica obliterates Trial^oL0.05% clobetasol ointment applied bid until improvement. ^JThen apply 0.05% betamethasone ointment bid for 1 month.
Very gradual taper off.
Discussed circumcision is curative for phimosis. Consider if no improvement.
231 statnote dot phrases - primary care phrase library
,.balanitis-bxo#
# Bartholin gland cyst/vulvar abscess Large (<5 cm) Conservative therapy w/ warm compresses and sit baths. Pain control. I&D with word catheter placement done in the office.
Start empiric abx w/ MRSA coverage - TMP-SMX (Bactrim).
bar tholin-cy st# small
# Bartholin gland cyst/vulvar abscess Small (<2 cm) Conservative therapy w/ warm compresses and sit baths.
If worsening or lesion points to the skin surface, consider I&D.
If not improving in 2 days start empiric abx - TMP-SMX (Bactrim).
,.bartholin-cyst*
56420
119 statnote dot phrases - primary care phrase library
,.bartholin-cyst-PE
vulva: tender, fluctuant mass with surrounding erythema and edema.
,.bartholin-cyst-proc
Bartholin gland cyst/abscess l&D with word catheter placement
Informed consent was obtained. Risks and benefits discussed with patient. Patient was placed in the dorsal lithotomy position. Labia and vagina was prepped in the usual sterile manner with betadine. 3 cc of 1% lidocaine w/ o epi were injected over intended site of entry. Incision made with an 11 scalpel blade immediately adjacent to the hymenal ring. Adson forceps with teeth were slid along the blade and grasped the tissue, defining a tract into the cyst. Abscess was drained completely and loculations were broken with a hemostat. Cultures were obtained. Word catheter was placed through the incision along the forceps. Balloon was inflated with 3 cc of saline. Catheter was gently tugged to ensure placement. Exposed portion of the catheter was tucked into the vagina. Patient tolerated procedure well.
colposcopy*
56821
vcolposcopy*w/ o-bx
56820
,.colposcopy-proc
Colposcopy After consent was obtained, speculum inserted and cervix visualized, No abnormalities noted. Green filter did not demonstrate any abnormalities. Vinegar applied, no lesions seen. Os very small, unable to use endocervical
120 statnote dot phrases - primary care phrase library
speculum to visualize canal. Biopsies taken at _5:00, 6:00 and ecc due to lack of visual correlates to pap smear findings. Minimal bleeding easily controlled with pressure and monsel’s solution. Patient tolerated procedure well. Pathology specimens sent. Patient will be notified with results.
Labia: Within normal limits.
Vagina: Within normal limits.
contraception
Pt requesting contraception.
Pt is on OCPs.
No h/o VTE, smoking, migraines w/ aura.
contraception#
# Bedbug bite Eradication of infestation discussed with patient. Prn oral antihistamines and topical steroids.
cheilitis
C/o dry and burning pain on lips. Reports some redness.
Does not improve with chapstick. Denies lip licking.
42 statnote dot phrases - primary care phrase library
cheilitis#
# Bell palsy No suspicion for CVA or Lyme.
Prednisone 60 mg po x7d. (Within 48 hrs).
No presumed HSV info - no antivirals rx.
Artificial tears/eye ointment, eye patch at night - prn incomplete eye closure.
Reassured complete recovery is likely.
,.bell-palsy-PE
Left face: complete ipsilateral paralysis of CN VII, including forehead.
cognitive-impairment
Family has concern for pt’s memory, forgetfulness. Report gradual decline.
No new medications or recent acute illness.
No h/o cardiovascular ds.
No depression.
Pt does not drive or manages finances.
No problems with language/word finding.
Not getting lost in familiar places.
103 statnote dot phrases - primary care phrase library
No behavior problems.
cognitive-impairment#
# Benign paroxysmal positional vertigo Patient education and reassurance.
Canalith repositioning - Epley maneuvers explained to patient, handout given to patient.
Meclizine pm.
,. dizzines s#Meniere
# Bicep-tendinitis, right Rest, ice, NSAIDs.
PT.
Consider steroid injection if not improving.
141 statnote dot phrases - primary care phrase library
,.bicep-tendinitis-PE
Right shoulder: tenderness over the bicipital groove. Pain reproduced with flexion of the arm against resistance.
Speed test.
Yergason test.
,.bicep-tendinitis-inj
Biceps tendon injection, Right Bicipital tendon (l°ng head) area of maximal tenderness was marked and then prepped in the usual sterile fashion. Using a 25 gauge 1.5 inch needle, 1 mL of lidocaine and triamcinolone - 20 mg was injected without difficulty. After injection, the patient was able to move the biceps through the full range of motion and a sterile dressing was applied. The patient tolerated the procedure well. Aftercare discussed.
,.biceps-tend-inj*
20550
buddy-tape
Right middle finger buddy taped to index finger.
,.buddy-tape*toes
29550
,.buddy-tape*fingers
29280
142 statnote dot phrases - primary care phrase library
callus
Pt c/o foot callus, right.
Causing considerable amount of pain and discomfort.
callus#
# Binge eating disorder Cognitive behavioral therapy. Referred to psychotherapy. Started SSRI.
219 statnote dot phrases - primary care phrase library
,.bipolar-ds
Bipolar disorder On no meds.
No recent manic episodes.
A few episodes of depression during last year. No suicidal ideation.
,.bipolar-ds#
# Bipolar disorder Stable w/o recent acute episodes.
Continue current management without changes. Psychosocial interventions and monitoring.
,.borderline
BPD Pt endorses Emotional instability and unpredictable outbursts.
Impulsivity.
Intense, unstable, and conflicted interpersonal relationships. Disturbed self-image, aims, and preferences.
Chronic feelings of emptiness.
Tendency for self-destructive behavior, including suicide gestures and behavior.
borderline#
# Borderline personality disorder Dx confirmed with MacLean Screening Instrument for BPD. Recommended Cognitive Behavioral Therapy.
Bibliotherapy.
220 statnote dot phrases - primary care phrase library
bulimia
Bulimia Pt reports recurrent episodes of binge eating with compensatory vomiting. Started with behavior a year ago, but worsening in the last 3 months. Concerned about weight and body shape.
Endorses palpitations and sore throat.
Endorses fluctuation in weight.
anxiety and depression.
buprenorphine
Opioid use disorder On buprenorphine.
Denies any side effects like sedation, headaches, nausea, constipation or insomnia.
Does not use any benzodiazepines or alcohol.
buprenorphine#
# Bulimia Cognitive behavioral therapy. Referred to psychotherapy. Nutrition and meal support. Referred to nutritionist. Started fluoxetine.
depression
Depression
221 statnote dot phrases - primary care phrase library
Compliant with SSRI. No side effects.
Not attending psychotherapy.
Denies feeling depressed or having little interest in doing things. No suicidal ideations.
depression#
# CAD Stable. No changes in medical management. Encouraged healthy lifestyle modifications. F/u with cardiology.
,.chf-hpi
CHF Patient is able to perform routine and desired activities of daily living. Denies CP, palpitations, SOB, orthopnea, leg swelling.
33 statnote dot phrases - primary care phrase library
Comfortable at rest.
Watching diet and sodium intake.
Not using tobacco, alcohol, or illegal drugs. No recent exacerbations.
Not part of home telemonitoring program. Not followed by cardiology.
,.chf#
# CI<D HIa(GFR45-59) IIIb(GFR30-44) Stable. No changes in management. Monitor renal function. Optimal BP and glycemic control. Dietary therapy. Low P and K. Anemia and bone mineral disorder screen: up-to-date. CMP, P, iPTH.
,.cystitis-int
Interstitial cystitis Pt c/o urgency, frequency and pelvic-floor pain. Reports food or stress triggers.
,.cystitis-int#
# CKD lIIa(GFR45-59) IIIb(GFR30-44) Stable. No changes in management. Monitor renal function. Optimal BP and glycemic control. Dietary therapy. Low P and K. Anemia and bone mineral disorder screen: up-to-date. CMP, P, iPTH.
,.cystitis-int
Interstitial cystitis Pt c/o urgency, frequency and pelvic-floor pain. Reports food or stress triggers.
,.cystitds-int#
# COPD Well controlled.
-FEV1 >50% of predicted. <2 exacerbations/yr (not hospitalized).
227 statnote dot phrases - primary care phrase library
-FEV1 <50% of predicted or >2 exacerbadons/yr (or hospitalized). Continue current inhalers.
No need for 02 tx. 02 Sat>92%, no signs of resp/right heart failure. Vaccines: flu, pneumococcal. UTD.
Encouraged physical activity.
Spirometry done <1 yr ago.
,.copd-exacerbation
Pt w/ COPD presents with SOB, productive cough and wheezing x days. No fevers or chills.
No UR1 symptoms.
No sick contacts.
Not smoking.
lung-nodule-incidental
Incidental lung nodule.
Pt is asymptomatic w/o any cough or constitutional symptoms. Immunocompetent w/o any malignancy that is actively under treatment or follow-up.
lung-nodule-incidental#
# CVA Residual hemiparesis.
Stable.
Continue antiplatelet and statin tx. Continue PT/OT/ST.
Optimal BP and glycemic control. Continue management for depression.
dementia
Family has concern for pt’s memory, forgetfulness. Report gradual decline.
No new medications or recent acute illness.
No h/o cardiovascular ds.
No depression.
Pt does not drive or manage finances.
No problems with language/word finding.
Not getting lost in familiar places.
No behavior problems.
105 statnote dot phrases - primary care phrase library
dementia#
# Callus Callus debulked by pairing skin w/ blade.
Apply salicylic acid plaster patch and replace qhs. RTC if lesion does not resolve in 1-2 wks.
,.callus-PE
Right foot:
diffuse skin thickening on
plantar aspect of prominent metatarsal dorsal aspect of toe joint
callus-paring-1 *
11055
,.callus-paring-2-4*
11056
,.callus-paring-proc
Pairing of callus Location: _ Using a no. 15 scalpel blade the hyperkeratotic tissue from _callus was removed by gradually shaving the lesion.
143 statnote dot phrases - primary care phrase library
Patient tolerated procedure well.
carpal- tunnel
C/o numbness of hands.
Nighttime worsening.
Numbness in the median nerve distribution. Symptoms are intermittent.
Onset is gradual.
Denies weakness of hand.
Hand intensive labor at work.
carpal-tunnel#
# Carpal tunnel Wrist splint.
NSAIDs.
Consider steroid injection if no improvement.
carpal- tunnel*
20526
carpal-tunnel-PE
Normal motor exam - no wasting of thenar eminence, normal pincer grasp. Normal sensation.
tinel sign.
phalen sign.
compression test.
144 statnote dot phrases - primary care phrase library
,.carpal-tunnel-inj
Carpal tunnel injection, right Informed consent was obtained from the patient. The volar aspect of the wrist was prepared with alcohol x3 and rested at a 30 degree angle on a rolled-up towel. The palmaris longus tendon was identified and a 25 gauge 1" needle was used to enter the carpal tunnel at the distal wrist crease and ulnar to the palmaris longus tendon. The needle was advanced through the carpal tunnel without any difficulty. No paresthesias were elicited. A mixture of 1 mL of lidocaine 1% w/o epi and 1 mL of 40 mg triamcinolone was injected . The medications flowed freely without any difficulty. After the procedure, the patient clenched and unclenched the fingers of both hands for a period of two minutes to distribute the medication. There were no complications throughout the procedure and good relief of symptoms following the procedure.
POST PROCEDURE INSTRUCTIONS: The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the extremity for the next 24 hours.
,.coccydynia
Pt c/o coccyx pain.
Pain occurs while sitting or transitioning between standing and sitting. Described as ache.
Radiates to lumbar spine and thigh.
Denies any injuries.
,.coccydynia#
# Carpometacarpal joint osteoarthritis, right Thumb spica splint.
NSAIDs prn.
Consider steroid injection.
,.thumb-cmc*
20600
,.thumb-cmc-PE
\
Right thumb: First metacarpal without any obvious deformities , full ROM. + grind test.
crepitus.
175 statnote dot phrases - primary care phrase library
,.thumb-cmc-inj
Location: _right 1st CMC joint Injection: 10 mg of triamcinolone + 0.5 mL of 2% lidocaine using a 25 G 5/8 in needle.
Entry point was marked.
Area was prepped in the usual sterile manner.
The needle was inserted into the affected area and the steroid was injected. Patient tolerated procedure well without complications.
Standard post-procedure care was explained and return precautions given.
,.tmj-PE
Limited jaw opening, no palpable spasm of facial muscles, no facial edema. + clicking of tmj, no crepitus. No deviation of mandible.
TMJ injection, _left Informed consent was obtained from the patient.
With the patient’s mouth in the open position the sulcus identified and marked.
The area was prepped in the usual sterile manner.
A 25 gauge needle was inserted into the affected area and a mixture of 0.5 cc of 1% lidocaine + 20 mg of triamcinolone were injected using a posterior approach at a 30-degree angle to the sagittal plane into the sulcus with the tip of the needle directed anteromedial toward the posterior aspect of the TMJ.
There were no complications during this procedure. The patient was able to move the jaw through its full range of motion.
POST PROCEDURE INSTRUCTIONS: The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the joint for the next 24 hours.
176 statnote dot phrases - primary care phrase library
,.tmj-inj*
20605
,.tmj-sd
TMJ sd
Pt complains of TMJ pain.
joint noise.
4- masticatory muscle tenderness. Denies depression or anxiety.
C/o headaches, earaches, neck pain.
,.tmj-sd#
# Carpometacarpal joint osteoarthritis, right Thumb spica splint.
NSAIDs prn.
Consider steroid injection.
,.thumb-cmc*
20600
,.thumb-cmc-PE
\
Right thumb: First metacarpal without any obvious deformities , full ROM. + grind test.
crepitus.
175 statnote dot phrases - primary care phrase library
,.thumb-cmc-inj
Location: _right 1st CMC joint Injection: 10 mg of triamcinolone + 0.5 mL of 2% lidocaine using a 25 G 5/8 in needle.
Entry point was marked.
Area was prepped in the usual sterile manner.
The needle was inserted into the affected area and the steroid was injected. Patient tolerated procedure well without complications.
Standard post-procedure care was explained and return precautions given.
,.tmj-PE
Limited jaw opening, no palpable spasm of facial muscles, no facial edema. + clicking of tmj, no crepitus. No deviation of mandible.
TMJ injection, _left Informed consent was obtained from the patient.
With the patient’s mouth in the open position the sulcus identified and marked.
The area was prepped in the usual sterile manner.
A 25 gauge needle was inserted into the affected area and a mixture of 0.5 cc of 1% lidocaine + 20 mg of triamcinolone were injected using a posterior approach at a 30-degree angle to the sagittal plane into the sulcus with the tip of the needle directed anteromedial toward the posterior aspect of the TMJ.
There were no complications during this procedure. The patient was able to move the jaw through its full range of motion.
POST PROCEDURE INSTRUCTIONS: The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the joint for the next 24 hours.
176 statnote dot phrases - primary care phrase library
,.tmj-inj*
20605
,.tmj-sd
TMJ sd
Pt complains of TMJ pain.
joint noise.
4- masticatory muscle tenderness. Denies depression or anxiety.
C/o headaches, earaches, neck pain.
,.tmj-sd#
# Cataracts Some functional visual impairment. Correction of refractive error. Consider intraocular lens implant. Referred for annual eye exam.
,.cataracts-PE
Bilateral eyes with cloudy intraocular lens.
cerumen-impaction
Pt c/o right ear decreased hearing and popping sensation x days.
cerumen-impaction#
# Cellulitis >2 cm surrounding erythema.
w/ pus - trial of PO Clindamycin or TMP/SMX (Bactrim), possible bite, anaerobic coverage - trial of amoxicillin/clavulanate (Augmentin).
Procedure precautions discussed with patient, including fever or worsening of purulent discharge.
,.cellulitis-PE
Macular erythema with indistinct borders on _. Warm and tender to touch. No fluctuance.
,.dental-clearance
Here for dental clearance.
Will undergo a dental procedure that involve manipulation of gingival tissue/periapical region of teeth or perforation of oral mucosa (including routine dental cleaning).
Not taking anticoagulants.
Pt has no prosthetic heart valves.
No h/o infectious endocarditis.
No h/o repaired congenital heart ds w/ residual shunts or valvular regurgitation.
No recent repair of congenital heart defects.
No h/o transplanted heart w/ valve regurgitations.
95 statnote dot phrases - primary care phrase library
dental-clearance#
# Cellulitis >2 cm surrounding erythema.
w/o pus - trial of Cephalexin or Dicloxacillin.
possible bite, anaerobic coverage - trial of amoxicillin/clavulanate (Augmentin).
Procedure precautions discussed with patient, including fever or worsening of purulent discharge.
94 statnote dot phrases - primary care phrase library
cellulitis#mild
# Cellulitis, mild Trial of mupirocin.
,.cellulitis#pus
# Cerumen impaction Ear lavage done. Avoid use of Q-tips.
,.chalazion-PE
Upper eyelid,_left: nontender, mild erythematous firm nodule just above tarsal plate.
conjunctivitis
C/o bilateral watery eye discharge for months. + itching.
No contact lens use.
No mucoid or purulent discharge.
74 statnote dot phrases - primary care phrase library
Eyelids not stuck together in am. No periocular tenderness.
Some rhinorrhea, pt has allergies.
,.conjunctivitis#bacterial
# Chalazion W/o significant surrounding cellulitis - amoxi/clav 500 Not distorting vision. - refer to ophtho.
Topical erythromycin.
Warm compresses + massage with diluted baby shampoo.
,.stye#-Hordeolum (Hurts)
# Cheilitis, eczematous Vaseline use.
Short course of triamcinolone. Avoid lip licking.
,.cheilitis-PE
Erythematous lips with some scaling, no fissures.
,.claravis#
Discussed Remember not to give your medication to anyone else. Do not donate blood. Make sure you complete your comprehension questions on ipledge and pick up your medication within 7 days or you may end up being delayed in your treatment.
,.claravis#F
Discussed Maintain 2 forms of birth control or abstinence as discussed with your provider (during treatment and a month after). Remember not to give your medication to anyone else. Do not donate blood. Make sure you complete your comprehension questions on ipledge and pick up your medication within 7 days or you may end up being delayed in your treatment. Pregnancy test a month after the last dose.
43 statnote dot phrases - primary care phrase library
cradle-cap
Mother brings infant w/ c/o crusty scales on scalp.
No other areas of the body affected.
No other rash. No fever. Otherwise healthy and feeding well.
cradle-cap#
# Childhood Obesity Discussed appropriate weight for age. Goal of losing 1 lb per month. Discussed 5210 behavioral changes. Encouraged/praised to build confidence.
sports-physical
Here for routine sports physical exam.
Has never been denied or restricted from participation in sports for any reason.
Denies any medical conditions such as asthma, anemia, diabetes or skin infections.
Denies family history of cardiac ds or sudden cardiac death.
Does not take any medications.
NKDA.
No recent illnesses, no G1 complaints, denies headaches or fatigue.
No recent hospitalizations or surgeries.
Regular diet, not a lot of junk food. Good appetite.
No recent excessive weight gain or loss.
No vision or hearing changes.
Denies experimenting with cigarettes, alcohol or street drugs.
No smokers at home.
Not sexually active.
Doing well in school; good student.
Wishes to participate in _.
187 statnote dot phrases - primary care phrase library
sports-physical#
# Chronic pain Medications providing over 30% improvement of pain and function.
< 90 MME.
No change in management. Using lowest effective dose.
Discussed alternative pharmacological and non-pharmacological pain relief therapies.
No suspected aberrant drug-taking behaviors.
cures
Cures report consistent with controlled substance agreement. Toxicology screen via urine up-to-date.
Controlled substance agreement signed.
Not suspicious for misuse of controlled medications.
}. die t-counseling
# Chronic use of benzodiazepines Medications providing over 30% improvement of Severity of panic attacks.
Hours of sleep.
Daily function.
No change in management. Using lowest effective dose.
Discussed alternative pharmacological and non-pharmacological therapies. No suspected aberrant drug-taking behaviors.
chronic-pain
Chronic pain Location: _ Pain w/o med:__/10 Pain w/ med: __/10 Taking medication as directed.
Including: hydrocodone, Tylenol, NSAIDs Psychosomatic symptoms including depression and insomnia are being treated.
Denies any side effects from medication including sedation and constipation.
Medications are not interfering with ADLs.
Addiction 4C: Denies craving, compulsive behavior, lack of self-control. Denies negative consequences as a result of using controlled substances.
2 statnote dot phrases - primary care phrase library
chronic-pain#
# Circumcision Pt tolerated well the procedure.
Aftercare and return precautions discussed w/ parent. Tylenol PRN.
Gave handout with information about procedure to parent. Return precautions discussed w/ parent.
F/u PRN.
,.circumcision-gomco
Procedure: Infant circumcision using the Gomco clamp.
184 statnote dot phrases - primary care phrase library
Anesthesia using dorsal penile nerve block, 1 cc of 1% lidocaine without epinephrine EBL: minimal.
Indications for procedure: Parent desired newborn circumcision of their male infant. Prior to the procedure, the infant was examined and has no signs of hypospadias or illness.
Risks, benefits, alternatives: Were discussed with the parent prior to the procedure, and informed consent was obtained. Signed consent form is in the infant’s medical record. Discussion included, but was not limited to: no medical necessity for the procedure, possible bleeding, infection, damage to the penis or adjacent organs, possible poor cosmetic result and possible need for repeat procedure. All their questions were answered. Complications: none.
Procedure: Area was prepped and draped in sterile fashion. Local anesthesia was administered as documented above under Anesthesia. After allowing sufficient time for the anesthesia to take effect, circumcision was performed in the usual sterile fashion using a 1.3 cm Gomco clamp. Good cosmesis and hemostasis was obtained. Vaseline gauze was applied. Infant tolerated the procedure well. Mother was instructed how to care for the circumcision site.
,.circumcision-mogen
Procedure: Infant circumcision using the Mogen clamp Anesthesia using Ring block, 1 cc of 1% lidocaine without epinephrine EBL: minimal.
Indications for procedure: Parent desired newborn circumcision of their male infant. Prior to the procedure, the infant was examined and has no signs of hypospadias or illness.
Risks, benefits, alternatives were discussed with the parent prior to the procedure, and informed consent was obtained. Signed consent form is in the infant’s medical record. Discussion included, but was not limited to no medical necessity for the procedure, possible bleeding, infection, damage to the penis or adjacent organs, possible poor cosmetic result and possible need for repeat procedure. All their questions were answered. Complications: none.
185 statnote dot phrases - primary care phrase library
Procedure: Area was prepped and draped in sterile fashion. Local anesthesia was administered as documented above under Anesthesia. After allowing sufficient time for the anesthesia to take effect, circumcision was performed in the usual sterile fashion using a Mogen clamp. Good cosmesis and hemostasis was obtained. Vaseline gauze was applied. Infant tolerated the procedure well. Mother was instructed how to care for the circumcision site.
,.down-sd
Accompanied by caregiver - parent.
Some cognitive disability.
Reports language delay.
Some verbal and nonverbal communication impairment. No behavioral difficulties.
Pt has a routine for daily activities.
Requires family support.
Community support:
Doing well at school.
Denies anxiety or depression.
Chronic constipation.
No h/o hypothyroidism.
No known h/o cardiovascular ds or VSD.
,.down-sd#
# Coccydynia Recommended rest.
Adjustment in seating with U-shaped/wedge shape cushions to relieve pressure on the coccyx.
Pain control with analgesics/ sitz baths.
145 statnote dot phrases - primary care phrase library
,.coccydynia-PE
Tenderness on palpation and movement of the tip of the coccyx.
,.corn#
# Cognitive impairment, mild Screen for B12 deficiency and hypothyroidism. Consider neuroimaging.
Mini-mental state examination score:
No depression.
concussion
S/p head trauma - direct.
Transmitted to the head by the acceleration-deceleration of the body on impact.
Denies loss of consciousness.
Event was witnessed.
Denies previous head injury, brain trauma or alcohol/substance abuse, c/o headache feeling foggy/slow dizziness/balance problems memory difficulties nausea/ vomiting
concussion#
# Concussion, w/o LOC No imaging needed at this point.
Normal physical neurologic exam.
No neuropsychological abnormalities. Physical rest.
Cognitive rest.
Education + gradual return to activity plan. Analgesia.
104 statnote dot phrases - primary care phrase library
Return if symptoms fail to improve or worsen.
,.cva-hpi
CVA Residual hemiparesis.
On PT/OT.
No problems with diet.
Pt compliant with and platelet therapy and stadns. No recent falls.
Endorses depression.
,.cva#
# Conjunctivitis Counseling on good hand hygiene, no contact lens use while sx present. Trial of cool compresses and liberal use of refrigerated artificial tears. Mod-severe bacterial Rx ofloxacin 0.3% 1 gtt qid x7d.
Rx polytrim 1 gtt qid x7d.
,. con j unctivitis #viral
# Conjunctivitis Counseling on good hand hygiene, no contact lens use while sx present. Trial of cool compresses and liberal use of refrigerated artificial tears. Viral / mild bacterial Reassured on self-limiting condition.
Rx 0.5% erythromycin oint qid x7d.
,.conjunctivitis-allergic#acute
# Constipation Trial of MiraLax.
Once pt has regular bowel movements start diet w/ high fiber content. Plenty of fluids.
Return if symptoms fail to improve or worsen
,.crohn-ds
Crohn’s disease On _. Compliant. No side effects.
Denies any abdominal pain, diarrhea, or blood in the stools. No recent flares.
No arthropathies, cutaneous or ocular manifestations.
,.crohn-ds#
# Corn Corn debulked by pairing skin w/ blade.
Apply salicylic acid plaster patch and replace qhs. Short soaks and pumice stone debridement at home. Footwear with extra toe space.
RTC if lesion does not resolve in 1-2 wks.
,.corn-PE
Right foot: plantar aspect / toe cleft.
Diffuse thickening with central “core” that is hyperkeratotic and tender to palpation.
corn-paring-1*
11055
corn-paring-2-4*
11056
corn-paring-procedure
Pairing of corn Location: _right foot.
Using a no. 15 scalpel blade the hyperkeratotic tissue from corn was removed by gradually shaving the lesion.
146 statnote dot phrases - primary care phrase library
Patient tolerated procedure well.
cyst-mucous
Patient has a history of right index finger DIP joint osteoarthritis. Status post joint injection.
Patient complains of a cyst that is enlarging on the site of injection.
cyst-mucous#
# Cradle cap Education, reassurance, conservative management.
Emollients and frequent shampooing to soften and remove scales. Consider ketoconazole shampoo if not improving. (2x/wk x 2wks).
,.cradle-cap-PE
Well-defined, erythematous macules and plaques w/ greasy, yellow scale involving frontal scalp and cheeks.
cryotherapy*1 -AK
17000
,. cr yo therapy*2-14-AK
17003
,. cryo therapy-AK
Cryotherapy Consent: Risks and benefits of therapy discussed with patient who voices understanding and agrees with planned care. No barriers to communication or understanding identified.
44 statnote dot phrases - primary care phrase library
After obtaining informed consent, the patient’s identity, procedure, and site were verified during a pause prior to proceeding with the minor surgical procedure as per universal protocol recommendations.
_ Actinic keratosis on _ treated with light cryotherapy using cryocautery with freeze thaw freeze technique with 2-3 mm surround freeze.
No complications. Procedure was well tolerated.
,.cryotherapy-SK
Cryotherapy Consent: Risks and benefits of therapy discussed with patient who voices understanding and agrees with planned care. No barriers to communication or understanding identified.
After obtaining informed consent, the patient’s identity, procedure, and site were verified during a pause prior to proceeding with the minor surgical procedure as per universal protocol recommendations.
_ Seborrheic keratosis lesions on _ treated with light cryotherapy using cryocautery with freeze thaw freeze technique with 2-3 mm surround freeze.
No complications. Procedure was well tolerated.
cryotherapy-wart
Cryotherapy Consent: Risks and benefits of therapy discussed with patient who voices understanding and agrees with planned care. No barriers to communication or understanding identified.
After obtaining informed consent, the patient’s identity, procedure, and site were verified during a pause prior to proceeding with the minor surgical procedure as per universal protocol recommendations.
_ Warts on _ treated with light cryotherapy using cryocautery with freeze thaw freeze technique with 2-3 mm surround freeze.
No complications. Procedure was well tolerated.
45 statnote dot phrases - primary care phrase library
cryo therapy-wart*1-14
17110
,.cryo therapy-wart*15
17111
cryotherapy-wart-plantar
Cryotherapy Consent: Risks and benefits of therapy discussed with patient who voices understanding and agrees with planned care. No barriers to communication or understanding identified.
After obtaining informed consent, the patient’s identity, procedure, and site were verified during a pause prior to proceeding with the minor surgical procedure as per universal protocol recommendations.
Wart was treated with shave excision of overlying keratin and then cryocauterized with freeze thaw freeze technique with 2-3 mm surround freeze.
No complications. Procedure was well tolerated.
,.dermatofibroma
Pt c/o bump on skin present for years. Located on leg.
Does not recall any trauma or insect bite. Denies any pain or itchiness.
No irritation with shaving.
dermatofibroma#
# Crohn’s disease Stable. No recent flares. Continue current management. Monitor CBC/CMP, vit B12 def. Not on chronic corticosteroids. Colonoscopy up-to-date.
Avoid NSAlDs.
Recommended high-fiber diet.
88 statnote dot phrases - primary care phrase library
»-gerd
GERD C/o heartburn/regurgitation.
Denies cough, shortness of breath, sore throat, changes of taste. No dysphagia.
No chest pain.
,-gerd#
# De Quervain tenosynovitis, right NSAlDs and splinting.
Consider first dorsal compartment steroid injection.
,.dequervain-PE
Right wrist: no obvious deformity, no edema, full ROM, radial styloid area w/ mild tenderness to palpation. + finkelstein test.
,.dequervain-inj
De Quervain tenosynovitis injection. Right Explained nature of condition to pt.
Refractory to medical management.
Pt opted for steroid tendon injection.
Steroid injection (10 mg triamcinolone + 0.5 mL plain lidocaine) between abductor pollicis longus and Extensor pollicis brevis tendon was given. Aftercare and return precautions discussed w/ pt.
Continue NSAIDs/Tylenol PRN.
Thumb spica wrist brace given to patient.
,. dequervain-in j*
20550
148 statnote dot phrases - primary care phrase library
,.dry-needling-proc
Dry needling/trigger point injection Discussed treatment options, risks, benefits and alternatives. Patient opted for trigger point injection.
Trigger point injection/dry needling to left lateral epicondyle was given. Patient signed informed consent. A 35 G needle was used.
Procedure was well tolerated.
Aftercare and return precautions discussed with patient.
epicondylitis
Patient c/o elbow pain.
During or following flexion and extension.
Exacerbates with repetitive movement or occupational activity. Denies decreased grip strength.
Located on lateral aspect of _ elbow.
epicondylitis#
# Dementia Screen for Bt 2 deficiency and hypothyroidism. Consider neuroimaging.
Mini-mental state examination score:
No depression.
,.dementia-f/u
Dementia Caregiver reports no significant decline since last visit. No significant changes in memory, forgetfulness.
No new medications or recent acute illness.
No depression.
Pt does not drive or manage finances.
No problems with language/word finding.
Not getting lost in familiar places.
No behavior problems.
,.dementia-f/u#
# Dementia Stable.
No depression.
Caregiver in place with good support. Recommended physical activity/exercise.
dizziness
Patient complaints of dizziness for days.
Described as “the room is spinning”.
Precipitated by sudden changes in position, head movement, getting up quickly.
Improved when eyes are closed.
106 statnote dot phrases - primary care phrase library
Episodes last _seconds. >2 times a day.
Denies decreased hearing. Denies tinnitus. Denies nausea or vomiting. Denies feeling faint. No history of syncope.
Does not take any blood pressure medications.
No history of cardiovascular disease or stroke.
No history of psychiatric conditions or migraines.
Denies any CP/SOB. Denies any numbness or weakness.
No history of trauma.
No recent UR1 or AOM.
No fever or rashes.
No new or changes in medications.
dizziness#
# Dental abscess S/p incision and drainage.
The patient tolerated the procedure well without complications.
Standard post-procedure care is explained and return precautions are given. Rx antibiotic sent, amoxicillin-clavulanate - f/u dentist.
Return precautions discussed with patient, including excessive bleeding, fever, worsening of purulent discharge.
242 statnote dot phrases - primary care phrase library
dental-abscess*
41800
,.dental-abscess-I&D-proc
Dental Abscess l&D Right upper quadrant _periapical/ periodontal molar abscess Informed verbal consent was obtained.
Risks (including recurrence, unaesthetic scar, failure to resolve), benefits, and alternatives were reviewed with patient.
The area was prepared in the usual, sterile manner.
Local anesthetic with 1% lidocaine w/ epinephrine instilled using 27ga needle.
Abscess I&D'ed using Noll blade. Abscess was probed, and purulent/ serosanguineous discharge was drained.
Abscess was probed, and pus was drained.
Bleeding was minimal.
,.dental-abscess-PE
Right upper quadrant _periapical/periodontal molar area. Fluctuant mass palpated. Tender to touch.
,.diastasis-recti-PE
Diffuse fusiform bulge with valsalva maneuver, abdominal contents protrude into the thinned, bulged midline fascia.
vexcision#
# Dental clearance Cleared for dental procedure.
Pt is not high risk for infective endocarditis.
No antibiotic prophylaxis required.
According to the American Heart Association antibiotic prophylaxis with dental procedures is reasonable for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis. Amoxicillin 2g 60 min prior to the dental procedure.
,.hepC
Hepatitis C No h/o IV drug use.
No h/o transfusion or organ transplantation.
Denies constitutional symptoms.
No jaundice, ascites, or symptoms of hepatic encephalopathy. Has not been treated.
Interested in treatment.
vhepC#
# Depression Stable. Continue SSR1 without dose changes.
PHQ-9 Score: _ moderate, recurrent.
Reviewed Cognitive Behavioral Therapy.
Recommended mindfulness meditation and exercise. Sleep hygiene. Ventilation and insight-oriented psychotherapy given for 16 minutes exclusively.
Psychoeducation: encouraged personality growth and development through coping techniques and problem-solving skills.
,.etoh
Not concerned about alcohol problem.
Drinks _ day/week.
Has ~ _ drinks when drinking.
Denies not being able to stop drinking once started. Not affecting daily life or interfering with responsibilities. Does not drink an “eye opener”.
Denies feeling of guilt/remorse.
Patient does smoke cigarettes.
,.etoh#
# Dermatofibroma Reassurance. Monitor.
46 statnote dot phrases - primary care phrase library
If lesion becomes symptomatic consider cryotherapy or intralesional corticosteroid injection.
,.dermatofibroma-PE
_ mm dark skin colored nodule, hard to palpation, fixed to skin surface but freely movable over the subcutis. Mild tenderness to palpation.
dry-skin
Pt c/o dry skin .
Some itchiness.
No improvement with OTC tx.
,.dry-skin#
# Desired contraception Discussed contraceptive means available including IUD, nuvaring, combination oral contraceptives, and nexplanon.
She wishes to proceed with _ Urine HCG obtained and is **__NEGATIVE__** Benefits and risks discussed with the patient.
,.depo
Desired contraception Discussed contraceptive means available including IUD, nuvaring, combination oral contraceptives, and nexplanon.
She wishes to proceed with Depo-Provera injection. Patient currently not taking any birth control.
LMP: wks ago.
No PMH of diabetes, hypertension, or smoking.
121 statnote dot phrases - primary care phrase library
,.depo#
Pregnancy test negative. Depo-provera was injected after patient signed informed consent. No complications. Benefits and risks discussed with the patient. Patient aware of amenorrhea/irregular bleeding, delayed fertility after discontinuation. Patient tolerated procedure well, f/u in 3 months for repeat injection.
dysmenorrhea
Pt c/o painful menstruation. Affecting daily activities. No HA, fatigue, N/V.
dysmenorrhea#
# Diabetes Mellitus type 2 Not Controlled. Hyperglycemia.
Continue current medications. No change in management. Patient is on aspirin, ACE1, and statin.
Lipid panel checked less than a year ago.
Microalbumin checked less than a year ago.
Foot exam and monofilament test done. Continue/Increase dietary efforts and physical activity. Routine diabetic retinopathy screening: up-to-date.
,.dm2-PE
Monofilament screen: normal sensation on feet. 2+ pulses. No ulcers.
69 statnote dot phrases - primary care phrase library
,.dm2-insulin
Insulin-dependent diabetes type 2 On _ units of Lantus qhs and _ units of Humalog qac. As well as metformin.
Compliant with medications. No hypoglycemic events.
Fasting blood glucose _ Postprandial blood glucose _ No complaints of foot pain or paresthesias.
Seen by ophthalmologist: <1 yr ago.
Following a low carb diet.
,.dm2-pomed
Diabetes type 2 On metformin, glipizide Compliant with medications. On ACEI. No hypoglycemic events. Not checking blood glucose at home.
No complaints of foot pain or paresthesias.
Seen by ophthalmologist <1 yr ago.
Following a low carb diet. Exercising.
,.hyperthyroidism
Graves' disease On methimazole. Compliant with medications. No side effects. Denies heat intolerance, sweating or unintentional weight loss. No tremors or palpitations.
hyperthyroidism#
# Diet/exercise counseling Counseled the patient on healthy diet and physical activity due to obesity, hypertension, diabetes, hyperlipidemia for 15 minutes.
fall-elderly
Pt c/o mechanical fall.
Tripped and lost balance.
Denies gait or balance impairment.
No muscle weakness.
No dementia or cognitive impairment.
No peripheral neuropathy.
Denies any dizziness or lightheadedness.
No new medications.
Environmental hazards: no loose rugs, poor lighting, clutter.
3 statnote dot phrases - primary care phrase library
fall-elderly#
# Digital mucous cyst Aspirated.
Wound care.
,.cyst-mucous-PE
Right index finger DIP joint: digital mucous cyst on radial aspect.
,.cyst-mucous-asp
Digital mucous cyst aspiration Right index finger Area was prepped in the usual sterile fashion.
Ethyl chloride was used for topical anesthesia.
An 18 G needle tip was inserted in the center of the cyst. Cyst contents were manually extruded.
Pt tolerated procedure well.
Sterile bandaid applied.
cyst-mucous-asp*
26160
147 statnote dot phrases - primary care phrase library
,.dequervain
Pt complains of pain in the base of the _right thumb for months. Worsening when lifting heavy objects.
,.dequervain#
# Dizziness No signs or symptoms of central vertigo.
Orthostatic signs are [negative].
History and provocative maneuvers on physical exam suggest peripheral etiology.
Most likely etiology BPPV.
,.dizziness#BPPV
# Down Syndrome Verbal and cognitive capacity, moderate impairment. Good educational/activity, continue daily routine. Family and social support: adequate.
(
186 statnote dot phrases - primary care phrase library
,.hand-foot-mouth-ds-PE
Multiple painful 1 -3 mm vesicles, some ulcerated and erythematous background involving perioral, bilateral hands and feet. Oral mucosa not involved.
obesity-childhood#
# Dry skin Avoid frequent baths/showers.
Liberal use of emollients. Eucerin/Aquaphor.
Mild soap/Dove.
Consider short course of hydrocortisone crm if not improving or worsening.
,.dry-skin-PE
Dry, dull, rough skin patches affecting lower extremities and abdomen.
eczema#
# Dysmenorrhea Trial of NSAIDs and hormonal contraception.
,.emb#
Abnormal uterine bleeding.
Endometrial biopsy done without complications. Endometrial sample set for path, we will call patient with results when available.
Usual post procedure warnings and aftercare instructions reviewed. Patient was discharged in good condition.
,.emb*
58100
122 statnote dot phrases - primary care phrase library
,.emb-proc
Endometrial biopsy with plastic endometrial aspirator (pipelle) After appropriate discussion of risks and benefits written informed consent was obtained. The patient was placed in the dorsal lithotomy position. A bimanual exam revealed normal size and position of the uterus. A sterile speculum was inserted. The cervix was visualized and prepped with iodine. A tenaculum was applied to the anterior lip of the cervix. The aspirator with internal piston was inserted through the cervix and into the uterine cavity. The depth of the uterus was _8cm. Negative pressure was built up by drawing back the piston. The sheath was rotated 360 degrees while withdrawing the aspirator from the fundus up to the internal os. Four passes were completed, each time the tissue collected was expressed into the formalin bottle. The sample was sent to pathology. The patient tolerated the procedure well with no complications. Return precautions and standard post-procedure care discussed with patient.
hot-flashes
Patient c/o hot flashes and night sweats. Menopausic.
Interfering with daily activities, bothersome. Causing irritability^ and mood swings.
hot-flashes#
# Eczema Short course of triamcinolone until severe dermatitis subsides (~week). Then switch to hydrocortisone (~week).
47 statnote dot phrases - primary care phrase library
Recommended occlusive dressing at night.
Trim nails, wear gloves at night.
Currendy no evidence of superimposed infecdon.
Liberal use of emollients (vaseline, moisturizer).
Discouraged prolonged use of topical corticosteroid d/1 skin atrophy. Avoid hot water.
Loratadine and benadryl prn itching. Topical benadryl.
Return if condition worsens or fails to improve.
Consider dermatology and/or allergist referral if no improvement.
,.eczema-PE
Erythematous plaques on extensor arms, evidence of excoriation.
j.folliculitis
Pt c/o red bumps on trunk and buttocks. Recent use of a hot tub.
Does not shave the area.
No new drugs.
folliculitis#
# Emergency contraception.
<120 hrs after unprotected intercourse.
Start medication ASAP.
Rx for Levonorgestrel (Plan B).
Repeat dosing of EC if vomiting med within 3 hrs of ingestion. Perform pregnancy test if menses delayed more than 1 wk.
,.pms-hpi
PMS Pt c/o depressed mood, irritability, and internal tension just before menses. + labile mood.
headaches.
breast tenderness, bloating.
130 statnote dot phrases - primary care phrase library
,.pms#
# Epicondylitis Rest + ice + NSAIDs + brace/strap.
PT exercises.
If no improvement consider steroid injection.
epicondylitis*
20551
149 statnote dot phrases - primary care phrase library
,.epicondylitis-lat-PE
Tenderness on lateral epicondyle. Pain during resisted wrist extension/ext rotation.
,.epicondylitis-lat-inj
Lateral epicondylitis steroid injection, Right After discussion of risks and benefits of steroid injection, including but not limited to infection, bleeding, discomfort with injection, adverse reaction to protein, and possibility of no improvement in pain symptoms patient gave verbal and written consent. Time-out performed and site of injection was verified and patient identified by name and DOB.
Elbow was prepped with isopropyl alcohol x 3. Ethyl chloride used for local anesthesia. 40 mg of kenalog mixed with 3 cc of l%lidocaine w/o epi was then injected into lateral epicondyle using a 25 gauge needle using the fanning approach. Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if knees become warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
,.epicondylitis-med-PE
Tenderness on the medial epicondyle. Pain during resisted wrist/forearm pronation/flexion.
,.epicondylitis-med-inj
Medial epicondylitis steroid injection, Right After discussion of risks and benefits of steroid injection, including but not limited to infection, bleeding, discomfort with injection, adverse reaction to protein, and possibility of no improvement in pain symptoms patient gave verbal and written consent. Time-out performed and site of injection was verified and patient identified by name and DOB.
150 statnote dot phrases - primary care phrase library
Elbow was prepped with isopropyl alcohol x 3. Ethyl chloride used for local anesthesia. 40 mg of kenalog mixed with 3 cc of l%lidocaine w/o epi was then injected into medial epicondyle using a 25 gauge needle using the fanning approach. Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if knees become warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
fibromyalgia
Fibromyalgia Compliant with amitriptyline.
Using tylenol/NSAlDs prn pain.
No recent exacerbations.
Good adherence to exercise and behavioral therapy. No sleep disruption.
Not interfering with daily functioning.
fibromyalgia#
# Epistaxis, anterior Recommended cool mist humidifier. Nasal saline spray + vaseline.
Prn afrin.
,.epistaxis-PE
Blood oozing from nasal septum.
,.epistaxis*cauterization/pack-ant
30901
,.epistaxis-cauterization
Cauterization of epistaxis, left nasal septum Afrin/epinephrine saturated gauze was packed into _left nasal space. Exam of nasal membrane revealed oozing from medial septum (Kiesselbach’s plexus area).
Silver nitrate was used for cauterization.
Patient tolerated procedure well.
Bacitracin was applied afterwards.
No need for expandable nasal sponge.
,.eustachian-tube-dys
Patient complains of right ear pain, sensation of ear fullness. Some hearing loss.
Recent UR1.
No history of allergies.
77 statnote dot phrases - primary care phrase library
,.eustachian-tube-dys#
# Erectile dysfunction Trial of sildenafil.
Discussed treatment of underlying condition. Discussed psychosexual therapy.
nephrolithiasis
Pt c/o flank pain, left.
Severe, radiates to groin.
Previous episode of nephrolithiasis. No fever. No N/V. No dysuria. Denies hematuria.
nephrolithiasis#
# Essential tremors Trial of propranolol. Consider primidone. Discussed side effects. Differential
Intentional tremors - cerebella. No dysmetria on exam.
Tremors at rest - Parkinson. No phasies or other suggestive exam findings.
,.tremor-PE
Bilateral upper extremity tremor activated by voluntary movement/holding hands outstretched.
Tremor absent with limbs relaxed. No head or voice involvement.
No dysmetria.
117 statnote dot phrases - primary care phrase library
10 OB/GYN
,.abnormal-vaginal-bleed
Pt c/o vaginal bleeding Metromenorrhagia for months.
Sexually active, not associated with intercourse.
Does not use OCP or other forms of contraception. LMP: wks ago.
Reports __regular periods q_d, lasts __d. _passing clots. Soaked pad/tampon q_h.
Bleeding does _ occur between menstrual periods. Menopausic, no use of HRT. Maternal menopause at age _. No h/o OB sx or c/s.
Denies personal or fam hx of bleeding disorders.
Denies use of anticoagulants.
Pt is _ obese, no known h/o PCOS.
abnormal-vaginal-bleed#
# Eustachian tube dysfunction Trial of decongestants and nasal steroids. Yawning/ Swallowing.
Toynbee maneuver.
glaucoma
Glaucoma On opt gtt.
Compliant.
Denies any loss of peripheral vision or eye pain.
glaucoma#
# Fall
Recommended use of a cane or a walker.
Reviewed medications. No modifications.
Vision assessment. Consider ophtho referral.
Recommended exercise for strength and balance training (tai-chi). Consider home safety assessment.
fatigue
Pt c/o fatigue x_ mo.
No SOB, CP, palpitations.
No menorrhagia.
No melena or blood in the stool. Does not skip meals.
Sleeps >6 hours.
Not overworked.
No stress.
fatigue#
# Fatigue History and physical exam do not suggest any organic illness associated with fatigue.
No side effects of medications or substance misuse.
No psychiatric issues.
Good sleep quality/quantity.
Sent pt for lab w/u.
vhospital f/u-transitional
Transitional care management. Patient was contacted within 2 business days of discharge. See note below for documentation.
4 statnote dot phrases - primary care phrase library
,.hospital-f/u
Here for hospital discharge follow-up. Pertinent laboratories were reviewed. Discharge records were reviewed.
In summary _
,.mari)uana
Patient reports using marijuana.
Using it for medical reasons.
Does not use more than one drug at a time.
Pt is able to stop using drug whenever wanted.
Does not report “blackouts or flashbacks” as a result of drug use. Patient does not feel bad or guilty about drug use.
Family has not complained about involvement with drugs. Denies any withdrawal symptoms.
Denies any medical problems as a result of drug use.
marijuana#
# Fibromyalgia Stable.
Continue amitriptyline, same dose.
Continue analgesics prn pain.
Non-pharmacologic therapies:
Encouraged pt to exercise early during the day.
Advised on sleep hygiene.
Advised on pt support including National Fibromyalgia Assoc, fmaware.org Consider cognitive behavioral therapy.
,.foosh
Pt c/o wrist pain, left.
After falling on an out-stretched hand with the wrist in extension. No deformities noted.
151 statnote dot phrases - primary care phrase library
Reports swelling after injury.
Denies any previous wrist injuries or surgery.
,.foosh-PE
Left wrist No obvious deformities such as “dinner-fork”. Some edema and area tender to palpation. Anatomic snuffbox not tender to palpation. Limited ROM d/1 pain.
NVI.
Elbow and shoulder joints wnl.
foot-pain-metatarsal
Pt c/o foot pain, right Causing pain around the ball of the foot Feels like a stone in the shoe Worse when walking barefoot
foot-pain-metatarsal#
# Folliculitis Reassured. Usually self limited.
Wash with antibacterial soap. Topical mupirocin. Prevent recurrence with BPO wash.
Cool, dry, loose clothing.
Consider po meds if recurrent/severe.
,.folliculitis-PE
Multiple follicular erythematous papules/pustules on _
48 statnote dot phrases - primary care phrase library
,.folliculitis-scalp
Pt c/o red bumps on the back of neck. Using topicals w/o significant improvement, pt uses razor/trimmer to shave head.
folliculitis-scalp#
# Folliculitis, scalp/neck Avoid shaving/trimming.
Trial of BPO wash and topical mupirocin.
fragile-nails
Pt c/o fragile nails and brittleness.
Household daily chores are particularly damaging. Denies any fatigue or h/o anemia.
fragile-nails#
# GERD Empiric low-dose PPI tx x 8 wks.
Maintenance and pm tx w/ H2RA afterwards.
No suspected reflux complications (Barret/stricture).
Lifestyle modification: wt loss, avoid meals 2-3h before bedtime. Consider eliminating food triggers: chocolate, caffeine, EtOH, acid/spicy food.
,.ibs-hpi
Patient complains of abdominal discomfort. Described as crampy. Located in the lower/mid abdomen. Can be mild to severe. Endorses alteration of bowel habits associated with pain.
Alternating diarrhea and constipation. Relief of pain with defecation. + Bloating. Improved with passage of flatus.
No nausea or vomiting.
,.ibs#constipation
# Ganglion cyst W/o neurovascular compromise. Activity modification and analgesia. Cyst aspiration discussed.
Splint recommended.
,.ganglion-cyst*
20612
,.ganglion-cyst-PE
lxl cm transilluminating subcutaneous mass on wrist. Not tender to palpation. Soft.
,.ganglion-cyst-proc
Ganglion cyst aspiration Wrist, right After discussion of the risks, benefits and alternative therapies available, the patient elected to proceed. After obtaining informed consent, the patient’s identity', procedure, and site were verified during a pause prior to proceeding
153 statnote dot phrases - primary care phrase library
with the minor surgical procedure as per universal protocol recommendations.
Area was cleansed with povidone/iodine swabs. Ethyl chloride was sprayed in the area for anesthesia. An 18-gauge needle attached to a 5 cc syringe was then used to aspirate the ganglion cyst, lcc mixture of 1% plain lidocaine and 20 mg of triamcinolone where then injected. Hemostasis was obtained by pressure. There were no complications.
,.gout
Gout Patient has had no attacks during last year.
Does not complain of joint pain.
Has not noticed any tofi formation.
Compliant with uric acid-lowering agent. Allopurinol.
Not using NSAIDs, colchicine, or steroid.
Not using diuretics.
Patient is not drinking alcohol/beer. Reduced intake of meats/seafood and dairy products.
,.gout#
# Gastrointestinal symptoms suggestive of Celiac ds Serologic testing (tTG/IgA) while pt is on a gluten-containing diet. If positive will sent to GI for endoscopy.
87 statnote dot phrases - primary care phrase library
constipation
Patient complains of constipation. Some straining/hard stools. Bowel movements - not daily.
constipation#
# Genital herpes First episode.
Valacyclovir 1000 bid x7d. Symptomatic tx of pain (po/topical). Screen for other STDs.
,.herpes-genital#recurrent
# Genital herpes Recurrent.
Valacyclovir 500 bid x3d. Symptomatic tx of pain (po/topical).
97 statnote dot phrases - primary care phrase library
,.hiv-hpi
HIV On antiretrovirals. Compliant. No side effects. No recent respiratory, GI, or skin infections. No recent hospitalizations.
neuropathy. Feet pain controlled.
,.hiv#
# Glaucoma Stable. Continue opt gtt.
Monitor intraocular pressure and symptoms like vision changes, redness or eye pain.
hearing-loss
Pt c/o gradually progressive hearing loss.
C/o difficulty understanding words/conversation in a busy/noisy environment.
No history of noise exposure.
,. hearing-lo s s #conduc tive
# Gout Controlled.
Continue with uric acid-lowering agent. No changes in management. Uric acid check (q6mo, goal <6).
CMP, CBC check (q6mo).
Recommended wt loss. Avoid food with high purine content.
, .gout-flare
Gout Patient complains of joint pain.
Right toe Drinks alcohol. High intake of meats/seafood and dairy products.
154 statnote dot phrases - primary care phrase library
Using NSAIDs with mild relief of pain. Not using diuretics.
gout-flare#
# Gout, acute Short course of high dose NSAIDs.
Consider steroid injection.
Check uric acid to confirm dx of gout.
Consider starting allopurinol if high, 2 wks after acute episode.
,.hallux-valgus
Hallux valgus C/o painful bilateral big toe. Exacerbated when using closed shoes. Present for years.
Worsening.
hallux-valgus#
# Gradual CHL Likely cerumen impaction. - ear lavage done. Eustachian tube dysfunction - trial of decongestant. Consider audiology evaluation.
78 statnote dot phrases - primary care phrase library
,.hearing-loss#presbycusis
# Gradual SNHL Most likely presbycusis.
Referred to audiology.
Consider amplification w/ hearing aids.
Discussed cost and infrequent insurance coverage. Listening strategies: lip reading, direct facing, slow speaking.
, .hearing-lo s s# sudden
# Gradual SNHL Most likely presbycusis.
Referred to audiology.
Consider amplification \v/ hearing aids.
Discussed cost and infrequent insurance coverage. Listening strategies: lip reading, direct facing, slow speaking.
,.hearing-loss#sudden
# Granuloma annulare Localized disease.
Trial of topical steroids.
Consider intralesional steroid injection or cryotherapy if not improving.
,.herpes-labialis
Pt c/o painful sore on lip.
Present for days.
Reports tingling sensation around lesion. Denies any fevers.
No other lesions.
,.herpes-labialis#
# Graves disease Stable. TSH checked less than a year ago. Continue current medications w/o change.
70 statnote dot phrases - primary care phrase library
hypothyroidism
Hypothyroidism Patient is on levothyroxine. Compliant with medication, denies any side effects like palpitations.
Denies any fatigue, weight gain, cold intolerance, constipation, or dry skin.
,.hypothyroidism#
# Grief Acute (<1 yr). No other psych/mental ds.
Discussed grief normal response to bereavement.
No tx indicated other than support from family and friends. Encouraged patient to maintain regular activities, sleep, exercise, and nutrition.
Consider support groups.
,.insomnia
Insomnia Hours of sleep at night: <6. Naps: no.
Timing: difficulty falling/staying asleep, early awakening. Daytime effects and symptoms include fatigue.
Sleep schedule/habits: 10-6, TV on.
Sleep environment: dark.
Denies snoring or kicking during the night.
Pt denies any depression or emotional stress.
Does not smoke.
Alcohol: occasional.
No night shift work.
223 statnote dot phrases - primary care phrase library
insomnia#
# HFrEF HFpEF NYHA I-no lim 11-sx w nl activity, 111-sx w minimal activity IV-sx at rest, a - no CAD. No sx/lim activity, b - min CAD. Mild sx/lim activity, c - mod CAD. Comft only at rest, c - severe CAD. Sx at rest.
LVEF <40% - on ACEi, BB.
Cautious use of diuretics.
DM, HTN, afib optimization of medical management.
Wt, edema check.
F/u w/ cardiology telemonitoring/ multidisciplinary ds management program. No anemia/Fe def.
AICD candidate LVEF < 35%, ischemic cardiomyopathy, NYHA 11/111 despite optimal medical rx for >3 mo.
1 yr expected survival and good functional status.
CRT QRS >120 ms.
,.cp-hpi
Pt c/o chest pain x wks. Pain located on right side.
34 statnote dot phrases - primary care phrase library
No radiation.
Described as pressure.
Lasts for a few minutes.
At rest. Not related to exertion. No SOB or palpitations.
No emotional stressors.
cp-atypical#
# HIV Stable. On antiretroviral therapy.
Optimal CD4 count. No need for prophylactic for opportunistic infections. Neuropathy stable.
,-prep
Pt with risky sexual behavior.
Interested in pre-exposure prophylaxis for HIV. No h/o HIV infection.
,.prep#
# HTN Not Controlled.
Continue current medications. No change in management. Discussed DASH diet and dietary sodium restrictions. Continue/Increase dietary efforts and physical activity.
,.le-edema
C/o lower extremity edema, bilateral. Some pain and discomfort.
High salt in diet.
No h/o CHF or CKD.
No SOB or orthopnea.
No new or changes in medications.
,.le-edema#
# Hallux valgus, bilateral Footwear adaptation to relieve pressure.
Consider surgical repair if significant deformity causing pain and affecting daily life.
hallux-valgus-PE
Lateral deviation of the hallux on the first metatarsal, some erythema on the medial bursa protecting the joint.
155 statnote dot phrases - primary care phrase library
ham string-sprain
Pt c/o pain in the posterior thigh, left, xl mo. Gradual onset.
Sudden onset after running jumping.
Pt felt a tearing sensation.
,. hams tring-sprain#
# Hamstring sprain, left Home physical therapy exercises.
Active ROM/strengthening. Isometric exercises.
TENS. Ice.
Pain control.
Gradual return to play. Importance of warm-up/stretching. Risk of reinjury.
,.hamstring-sprain-PE
Left hamstring area: no masses, tender to palpation, pain reproduced with resisted flexion. Knee with full ROM.
,.hip-PE
Hip Exam: Right Soft tissue swelling not appreciated. Gait: antalgic.
Trochanteric not TTP.
Sciatic Notch not TTP.
Anterior hip TTP.
Full overall ROM and Strength. Ober’s Test: neg.
Log Roll: + FADERs: + FABIRs: +
156 statnote dot phrases - primary care phrase library
NV1.
,.hip-oa
Pt c/o hip pan, right.
Denies any injuries.
No Locking/Catching.
No Snapping.
Worsens with ambulation. Alleviating Factors: NSAIDs. No Prior Injuries/Surgeries.
,.hip-oa#
# Health Maintenance
19 statnote dot phrases - primary care phrase library
(>18) Depression screen: denies feeling depressed or having little pleasure in doing things.
(>35) Lipid disorders screening: up-to-date. Not on statins, 10-yr ASCVD risk <7.5%.
(45/55-79) Aspirin to prevent CVD: not taking aspirin. ASCVD <10%. (51-71) Hepatitis screening: sent, born between 1945-1965.
(50-75) Colorectal cancer screening: up-to-date.
(>65) Fall prevention: At increased risk of falls. On vitamin D.
(>65) Osteoporosis: Not at risk. Not a smoker or daily alcohol use, BMI>21, no family history.
Female (50-74) Breast cancer screening: up-to-date, last mammogram on <2 yrs ago - normal.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>60) Zoster vaccine: rx sent.
(>65,19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: up-to-date.
Smoker (55-80) Lung cancer screening: Pt has a 30 pack-yr smoking history and currently smokes or quit <15 yrs ago.
Tobacco use: counseling on cessation.
Counseled on healthy diet and physical activity
(60) ACP
20 statnote dot phrases - primary care phrase library
,.health-maintenance-M 18+
if
# Health Maintenance
17 statnote dot phrases - primary care phrase library
(>18) Depression screen: denies feeling depressed or having little pleasure in doing things.
(>35) Lipid disorders screening: up-to-date. Not on statins, 10-yr ASCVD risk <7.5%.
(45/55-79) Aspirin to prevent CVD: not taking aspirin. ASCVD <10%. (51-71) Hepatitis screening: sent, born between 1945-1965.
(50-75) Colorectal cancer screening: up-to-date.
Female (21-65) Cervical cancer screening: up-to-date, last pap-smear <3 yrs ago normal.
(50-74) Breast cancer screening: up-to-date, last mammogram on <2 yrs ago - normal.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>65,19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: n/a.
Smoker (55-80) Lung cancer screening: Pt has a 30 pack-year smoking history and currently smokes or quit <15 yrs ago.
Tobacco use: counseling on cessation.
Counseled on healthy diet and physical activity.
,.health-maintenance-F60+
# Health Maintenance (<24) Sexually active, STD/HIV screening: sent for labs.
(>18) Depression screen: denies feeling depressed or having little pleasure in doing things.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>65,19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: N/A.
Smoker Tobacco use: counseling on cessation.
Counseled on healthy diet and physical activity
,.health-maintcnance-M25+
# Health Maintenance (<24) Sexually active, STD/HIV screening: sent for labs.
(>18) Depression screen: denies feeling depressed or having litde pleasure in doing things.
Female (<50) Contraception: not interested.
(21-65) Cervical cancer screening: up-to-date, last pap-smear <3 yrs ago normal.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>65, 19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: n/a.
\
16 statnote dot phrases - primary care phrase library
Smoker Tobacco use: counseling on cessation.
Counseled on healthy diet and physical activity
,.health-maintenance-F25+
# Health Maintenance (>18) Depression screen: denies feeling depressed or having litde pleasure in doing things.
(>35) Lipid disorders screening: up-to-date. Not on statins, 10-yr ASCVD risk <7.5%.
(45/55-79) Aspirin to prevent CVD: not taking aspirin. ASCVD <10%. (51-71) Hepatitis screening: sent, born between 1945-1965.
(50-75) Colorectal cancer screening: up-to-date.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>65, 19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: N/A
Smoker (55-80) Lung cancer screening: Pt has a 30 pack-year smoking history and currently smokes or quit <15 yrs ago.
Tobacco use: counseling on cessation.
V
Counseled on healthy diet and physical activity.
,.health-maintenance-M60+
# Health Maintenance (>18) Depression screen: denies feeling depressed or having little pleasure in doing things.
(>35) Lipid disorders screening: up-to-date. Not on statins, 10-yr ASCVD risk <7.5%.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>65,19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: N/A.
Smoker Tobacco use: counseling on cessation.
21 statnote dot phrases - primary care phrase library
Counseled on healthy diet and physical activity.
e
,.health-maintenance-M50+
# Health Maintenance (>18) Depression screen: denies feeling depressed or having little pleasure in doing things.
(>35) Lipid disorders screening: up-to-date. Not on statins, 10-yr ASCVD risk <7.5%.
(45/55-79) Aspirin to prevent CVD: not taking aspirin. ASCVD <10%. (51-71) Hepatitis screening: sent, born between 1945-1965.
(50-75) Colorectal cancer screening: up-to-date.
23 statnote dot phrases - primary care phrase library
(>65) Fall prevention: At increased risk of falls. On vitamin D. (>65) Osteoporosis: Not at risk. Not a smoker or daily alcohol use, BMI>21, no family history.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>60) Zoster vaccine: rx sent.
(>65,19-65 DM/COPD^Ast/CHF) Pneumonia vaccine: up-to-date.
Smoker (55-80) Lung cancer screening: Pt has a 30 pack-year smoking history and currendy smokes or quit <15 yrs ago.
(65-75 M) AAA screening: up-to-date.
Tobacco use: counseling on cessation.
Counseled on healthy diet and physical activity
(60) ACP
physical
Here for Annual Preventive Physical Exam / Establish care.
Date of last physical: over 1 year.
Patient does not smoke.
EtOH: occasional. Not worried/guilty about drinking habits. No drug abuse.
Diet: regular.
Exercise: regularly.
Occupation: _.
Lives at home.
24 statnote dot phrases - primary care phrase library
No family history of diabetes, hypertension, cardiovascular disease, cancer.
Problem List
,.physical-F
Here for Annual Preventive Physical Exam / Establish care.
Date of last physical: over 1 year.
Patient does not smoke.
EtOH: occasional. Not worried/guilty about drinking habits.
No drug abuse.
Diet: regular.
Exercise: regularly.
Occupation: _.
Lives at home.
No family history of diabetes, hypertension, cardiovascular disease, cancer.
Well woman exam Pt has never had any abnormal pap smears.
Her last pap smear was > 3 yrs ago.
Pt is sexually active w/ only one partner.
Contraception used: none.
Not interested in GC/Chlam testing.
Denies any intimate partner violence.
Pt denies any abnormal vaginal bleeding or any vaginal d/c.
Pt is regular and denies any metromenorrhagia.
I
Denies any breast masses or abnormalities on self-breast exam.
Problem List
,.physical-F>50
Here for Annual Preventive Physical Exam / Establish care.
Date of last physical: over 1 year.
25 statnote dot phrases - primary care phrase library
Patient does not smoke.
EtOH: occasional. Not worried/guilty about drinking habits.
No drug abuse.
Diet: regular.
Exercise: regularly.
Occupation: _.
Lives at home.
No family history of diabetes, hypertension, cardiovascular disease, cancer.
Well woman exam Pt has never had any abnormal pap smears.
Her last pap smear was >3 yrs ago.
Pt is sexually acdve w/ only one partner.
Denies any inornate partner violence.
Menopausic.
Pt denies any abnormal vaginal bleeding or any vaginal d/c. Denies any breast masses or abnormalities on self-breast exam.
Problem List
,.wellness-exam Here for Senior Assessment/yearly wellness exam.
Date of last physical: over 1 year.
Current healthcare providers/suppliers:
Denies feeling depressed or having litde interest in doing things. Denies sleep changes, loss of interest, guilt, lack of energy, reduced cognition or difficulty concentrating, change in appetite, psychomotor changes, suicide ideation.
PHQ-9 Score:
Functional ability/safety Hearing: _ normal. ADL’s: Independent.
26 statnote dot phrases - primary care phrase library
No impairment for bed mobility, transfers, ambulation, dressing, eating, or toileting and personal hygiene.
_ Requires setup help only. One person physical assistant.
Fall risk: _ no recent falls.
Home safety: feels safe at home.
Patient does not smoke.
EtOH: occasional. Not worried/guilty about drinking habits.
No drug abuse.
Diet: regular.
Exercise: regularly.
Occupation: _.
Lives at home.
No family history of diabetes, hypertension, cardiac disease, cancer.
Problem List
,.WWC#
# Health Maintenance (>18) Depression screen: denies feeling depressed or having little pleasure in doing things.
v
18 statnote dot phrases - primary care phrase library
(>35) Lipid disorders screening: up-to-date. Not on statins, 10-yr ASCVD risk <7.5%.
(45/55-79) Aspirin to prevent CVD: not taking aspirin. ASCVD <10%. (51-71) Hepatitis screening: sent, born between 1945-1965.
(50-75) Colorectal cancer screening: up-to-date.
Female (21-65) Cervical cancer screening: up-to-date, last pap-smear <3 yrs ago normal.
(50-74) Breast cancer screening: up-to-date, last mammogram on <2 yrs ago - normal.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>60) Zoster vaccine: rx sent.
(>65,19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: up-to-date.
Smoker (55-80) Lung cancer screening: Pt has a 30 pack-year smoking history and currently smokes or quit <15 yrs ago.
Tobacco use: counseling on cessation.
Counseled on healthy diet and physical activity
(60) ACP
,.health-maintenance-F65+
# Health Maintenance (>18) Depression screen: denies feeling depressed or having little pleasure in doing things.
(>35) Lipid disorders screening: up-to-date. Not on statins, 10-yr ASCVD risk <7.5%.
Female (<50) Contraception: not interested.
(21-65) Cervical cancer screening: up-to-date, last pap-smear <3 yrs ago normal.
Vaccines Tdap: up-to-date.
Influenza vaccine: advised to get vaccine during influenza season Oct-May. (>65,19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: n/a.
Smoker Tobacco use: counseling on cessation.
Counseled on healthy diet and physical activity.
,.health-maintenance-F50+
# Health Maintenance (>18) Depression screen: denies feeling depressed or having little pleasure in doing things.
22 statnote dot phrases - primary care phrase library
(>35) Lipid disorders screening: up-to-date. Not on statins, 10-yr ASCVD risk <7.5%.
(45/55-79) Aspirin to prevent CVD: not taking aspirin. ASCVD <10%. (51-71) Hepatitis screening: sent, born between 1945-1965.
(50-75) Colorectal cancer screening: up-to-date.
Vaccines Tdap: up-to-date.
Influen2a vaccine: advised to get vaccine during influenza season Oct-May. (>60) Zoster vaccine: rx sent.
(>65,19-65 DM/COPD,Ast/CHF) Pneumonia vaccine: up-to-date.
Smoker (55-80) Lung cancer screening: Pt has a 30 pack-year smoking history and currendy smokes or quit <15 yrs ago.
Tobacco use: counseling on cessation.
Counseled on healthy diet and physical activity.
(60) ACP
,.health-maintenance-M65+
f
# Hemorrhoids, external Dietary and lifestyle modification. Fiber and fluids.
Sitz baths.
Po analgesics and topical anesthetics. Desitin (zinc oxide topical).
Baby wipes.
,.hemorrhoids
Hemorrhoids Pt c/o perianal pain/discomfort. + anal pruritus.
Endorses constipation.
No recent pregnancy.
spotting when wiping after BM. Denies rectal bleeding.
Tender palpable rectal lesion. Denies any rectal prolapsing mass.
hemorrhoids#
# Hemorrhoids, internal Dietary and lifestyle modification.
245 statnote dot phrases - primary care phrase library
Fiber and fluids.
Short-term topical corticosteroids.
Grade 2-3 (prolapse/req manual reduction). Consider rubber band ligation.
hernia#
# Hepatitis C No cirrhosis. Eval liver enzymes. Treatment naive. Interested in treatment. Recheck viral load.
Referral to GI.
herpes-genital
Pt c/o painful sore on genitals.
Present for days.
Reports tingling sensation around lesion. Denies any fevers.
96 statnote dot phrases - primary care phrase library
No dysuria. Recurrent episode.
herpes-genital-recurrent
Pt c/o painful sore on genitals.
Present for days.
Reports tingling sensation around lesion. Denies any fevers.
No dysuria.
New sexual contact.
,.herpes-genital-PE
Multiple tender genital lesions, vesicles/crusted papules.
,.herpes-genital#
# Hernia, _ Symptomatic.
Candidate for surgical repair.
Warned about signs and symptoms of incarceration or obstruction.
,.hernia-PE
Reducible hernia palpated on _. Enlarges with valsalva maneuver.
hernia
Pt c/o discomfort and bulging mass on _. Denies any pain.
No nausea, vomiting, constipation.
,.i&d-abscess*
10060
,.i&d-abscess-proc
Abscess I&D Fluctuant area on right _. Measuring _ cm.
246 statnote dot phrases - primary care phrase library
Local anesthesia achieved with approx. 4 cc of 1% lidocaine without epinephrine. Area cleaned with 10% betadine solution.
3 mm incision made with sterile #11 blade scalpel. Copious amounts of yellow purulent discharge expressed. Sterile packing placed in the incision. Wound dressed with dry, sterile dressing. Pt tolerated procedure well.
,.i&d-boil-proc
Boil l&D Location: right _.
Dimensions: lxl cm.
Consent obtained.
Local anesthesia achieved with ethyl chloride. Area cleaned with alcohol. 2 mm incision made with 18 G needle. Small amount of white thick material was expressed.
Hemostasis achieved with compression.
Wound dressed with dry, sterile dressing. Pt tolerated procedure well.
, .i&d-puncture-aspiration*ab s ce s s / cys t / boil/ hematoma
10160
,.i&d-puncture-aspiration-proc-abscess/cyst/boil/ hematoma
abscess/cyst/boil/hematoma puncture aspiration Location: right _ Dimensions: lxl cm Consent obtained.
Local anesthesia achieved with ethyl chloride. Area cleaned with alcohol. Puncture aspiration made with 18 G needle. Small amount of white thick material was expressed.
Hemostasis achieved with compression.
247 statnote dot phrases - primary care phrase library
Wound dressed with dry, sterile dressing. Pt tolerated procedure well.
,.laceration-proc
Laceration repair Location: _ Size: _ cm
Patient was positioned appropriately. 5 cc lidocaine without epinephrine was used as a local anesthetic. NaCl was used for irrigation. Patient was sterile draped with wound exposed.
Wound closed with 4-0 nylon suture, _ simple interrupted sutures placed with good approximation. Procedure tolerated well without complications. Wound dressed with bacitracin and sterile gauze.
lipoma
Patient c/o a mass on _ Painless.
Increasing in size.
Present for several months.
lipoma#
# Herpes labialis Po valacyclovir 2g bid xld.
topical antiviral, docosanol 10%.
Symptomatic tx w/ nsaids/tylenol, topical lidocaine.
,.herpes-labialis-PE
Single ulcer along the Vermillion border on left upper lip.
,.hyperhidrosis
Pt c/o of excessive palmar and plantar sweating. Started when she was young.
No severe facial, axillary or generalized sweating.
!
50 statnote dot phrases - primary care phrase library
,.hyperhidrosis#
# Herpes zoster Immunocompetent pt.
Mild pain.
Start po antiviral (valacyclovir lg tidx7d). Prn analgesics, calamine lotion.
,.shingles-PE
Grouped vesicles on an erythematous base confined to a distinct dermatome on _ without crossing the midline.
!■
62 statnote dot phrases - primary care phrase library
,.sk-hpi
Pt c/o lesion on _torso painless but c/o itching/irritation. No bleeding.
,.sk#
# Hiccups, persistent Did not improve with nasopharynx stimulation, supraorbital pressure, carotid sinus massage.
Trial of metoclopramide 5 mg tid.
,.mci#f/U
# High-risk sex behavior
98 statnote dot phrases - primary care phrase library
Start HIV on-demand PrEP.
Safe-sex.
Check and monitor renal fx, HIV/STD.
Discussed PrEP on-demand is not FDA approved.
It is taken 2 to 24 hours prior to sexual activity, one tablet is then taken daily while sexually active, and then continued for two more days after sexual activity has stopped.
,.std-hpi
New sexual partner.
Desires to be screened for STDs. Denies any dysuria or penile discharge. No genital lesions.
,.std#
# High-risk sex behavior Start PrEP with Truvada.
Monitor adherence.
HIV/STD test q3mo.
Discussed safe sex.
Check BMP.
No risk factors for renal ds. No UA needed.
,.prep#on-demand
# Hip OA, right NSAIDs/tylenol prn.
ROM and strengthening exercises.
Discussed wt loss.
Consider intra-articular corticosteroid injection.
,.ingrown-toenail
Patient c/o pain, redness, and swelling of corner of toenail. Affecting right big toe.
No purulence.
Reports no previous episode.
No h/o trauma.
Proper fitting shoes.
ingrown-toenail#
# Hordeolum W/o significant surrounding cellulitis - amoxi/clav 500 Not distorting vision. - refer to ophtho.
Topical erythromycin.
Warm compresses + massage with diluted baby shampoo.
84 statnote dot phrases - primary care phrase library
,.stye-PE-chalazion
Right upper eyelid swelling and erythema with a painless, rubbery, nodular lesion.
,.stye-PE-hordeolum
Right upper eyelid: tender, mild erythematous firm nodule just above tarsal plate.
subconjunctival-hemorrhage
Pt c/o bright red patch on_left eye x days. Painless, no denies any trauma.
Reports coughing, rubbing eye.
Denies any vision problems.
Not using any anticoagulants.
subconjunctival-hemorrhage#
# Hyperhidrosis Trial of topical aluminum chloride.
,.hyperhidrosis-PE
Excess sweat noted bilaterally on the palms of the hands.
impetigo#
# Hyperlipidemia Stable. Continue with current management without changes. Discussed healthy diet and lifestyle.
,.htn-hpi
Hypertension On Compliant with medications. Does not report any headaches, blurry vision, dizziness, chest pain, shortness of breath, or palpitations. Following a low salt diet. Exercising.
35 statnote dot phrases - primary care phrase library
,.htn#
# Hypothyroidism Stable. TSH checked less than a year ago. Continue current medications w/o change.
low-testosterone
Pt c/o decreased libido, erectile dysfunction with loss of morning erections. Denies gynecomastia, shrinking/small testes, or infertility.
Also reports fatigue and decreased energy levels.
,.low-testosterone#
# IT band Sd, right
160 statnote dot phrases - primary care phrase library
NSAIDs for pain and inflammation. Activity modification.
,.itbandSd-PE
Noble test, w/ compression tenderness 2cm proximal to the lateral femoral epicondyle on extension.
Ober test, showing tightness of the IT band.
,.knee#
# IUD surveillance IUD strings visualized.
No complications.
Reassured some spotting expected during the first few months. Counseled on safe sex to avoid STDs.
F/u prn.
menopause
Menopause Onset: less than 10 years.
Patient c/o hot flashes and night sweats.
Interfering with daily activities, bothersome.
Patient tried behavioral/lifestyle modifications for at least 3 months without adequate response.
menopause#
# Impetigo Contact precautions.
Localized - topical mupirocin. Widespread - po abx (cephalexin).
,.impetigo-PE
“Honey-crusted” plaques with small inflammatory halos.
,.intralesion-inj*
11900
,.intralesion-inj ection
Intralesional steroid injection.
After consent was obtained.
Area was cleaned with betadine.
0.25 mL of Kenalog 40 mg/mL was injected on lesion _
51 statnote dot phrases - primary care phrase library
keloid-injection
Intralesional steroid injection After consent was obtained.
Area was cleaned with betadine.
0.25 mL of Kenalog 40 mg/mL was injected on keloid scar on left ear lobule.
,.keloid-scar
Pt c/o slowly growing scar on _. Inciting event: body piercing, surgery. No itchiness, tingling or pain.
keloid-scar#
# Incidental lung nodule Asymptomatic.
Immunocompetent w/o any malignancy. Size: _ mm.
Per radiology, repeat chest CT in 12 mo. Unchanged.
No further follow-up per radiology.
228 statnote dot phrases - primary care phrase library
,.lung-nodule-lung-ca-screen
Lung nodule detected during lung cancer screening.
Pt is asymptomatic w/o any cough or constitutional symptoms. Not smoking.
vlung-nodule-lung-ca-screen#
# Infertility Meets criteria - frequent unprotected sex recommended.
Semen analysis.
Ovulatory function assessment.
OTC ovulatory prediction kit to detect LH surge.
If progesterone <3 —> prolactin, TSH, LH/FSH r/o PCOS.
35 y/o - test ovarian reserve - menstrual cycle day 3 FSH and estradiol level
,.iud-proc-mirena
IUD Placement - Mirena After appropriate discussion of risks and benefits of IUD placement, written informed consent was obtained. Urine pregnancy test was negative. A bimanual exam revealed normal size and position of the uterus. The patient was placed in the dorsal lithotomy position, and a sterile speculum was inserted. The cervix was visualized and prepped with iodine. A tenaculum was applied to the anterior lip of the cervix. A sound was placed through the cervical os in sterile fashion, and the uterus sounded to _8 cm. The IUD was loaded into the applicator in the usual fashion and the indicator placed according to the sound. The applicator was inserted into the cervix and the intrauterine device placed high in the endometrial cavity. The applicator was withdrawn and the strings trimmed. The patient tolerated the procedure well with no complications.
124 statnote dot phrases - primary care phrase library
,.iud-proc-paragard
IUD Placement - Paragard After appropriate discussion of risks and benefits of IUD placement, written informed consent was obtained. Urine pregnancy test was negative. A bimanual exam revealed normal size and position of the uterus. The patient was placed in the dorsal lithotomy position, and a sterile speculum was inserted. The cervix was visualized and prepped with iodine. A tenaculum was applied to the anterior lip of the cervix. A sound was placed through the cervical os in sterile fashion, and the uterus sounded to _8 cm. The IUD was loaded into the applicator in the usual fashion and the indicator placed according to the sound. The applicator was inserted into the cervix and the intrauterine device placed high in the endometrial cavity. The applicator was withdrawn and the strings trimmed. The patient tolerated the procedure well with no complications.
,.iud-insertion*
58300
,.iud-removal*
58301
,.iud-removal-proc
Intrauterine Device (IUD) Removal
After appropriate discussion of risks and benefits of IUD removal, informed consent was obtained. The patient was placed in the dorsal lithotomy position, and a speculum was inserted. The IUD strings were seen at external os and grasped with sterile ring forceps and removed without difficulty. An IUD hook or other device was not needed. Patient tolerated the procedure well without complications.
125 statnote dot phrases - primary care phrase library
Back up contraception was discussed.
,.iud-surveiUance#
# Ingrown toenail, right Well-fitted shoes with a wide toe box recommended.
157 statnote dot phrases - primary care phrase library
Trim toenails properly. Avoid cutting back to the lateral margins in a curved pattern.
Soak toe in warm water, followed by application of topical antibiotics.
,.ingrown-toenail*
11750
,.ingrown-toenail-PE
Left big toe: medial ingrown toenail, there is edema and mild erythema of the nail fold. No purulence or ulceration.
, .ingrown-toenail-proc
Right lateral great toe partial nail avulsion:
Skin cleaned with 70% alcohol swab.
Digital block performed with 1:1 ratio of 1% Lidocaine (without Epinephrine) + 0.25% Bupivacaine.
Area was prepped in usual sterile fashion with 10% Iodine swab and sterile drapes, and sterile gloves used.
Nail elevator used to separate lateral aspect of nail from the nail bed. Hemostat used to clamp lateral aspect of nail.
Podiatry scissors used to cut lateral 1 /4 of the nail.
Nail removed by turning hemostat clockwise and the nail was pulled out easily.
Nailbed cauterized with silver nitrate also to achieve hemostasis, in addition to applying direct pressure.
Neosporin applied and toe was wrapped with gauze and kerlix bandage roll.
,.injection#
Explained nature of condition to pt. Refractory to medical management.
158 statnote dot phrases - primary care phrase library
Pt opted for steroid intra-articuJar injection.
Steroid injection to _ was given.
Aftercare and return precautions discussed w/ pt.
Continue NSAIDs/Tylenol PRN.
Gave handout with information about condition and stretch/strengthening exercises.
F/u PRN.
,.injection*intermediate-joint (TMJ,AC5W,E,A)
20605
,.inj ection*maj or-j oint
20610
,.injectdon*small- joint
20600
injection-knee
Knee steroid injection, right After discussion of risks and benefits of steroid injection, including but not limited to infection, bleeding, discomfort with injection, adverse reaction to protein, and possibility of no improvement in pain symptoms patient gave verbal and written consent. Time-out performed and site of injection was verified and patient identified by name and DOB. Knee was prepped with betadine x 3. Ethyl chloride used for local anesthesia. 40 mg of triamcinolone mixed with 4 cc of l%lidocaine w/o epi was then injected into knee using a 22 gauge needle using the inferolateral approach. Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if knees become warm.
159 statnote dot phrases - primary care phrase library
red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
,.inj ection-shoulder
Right shoulder injection After discussion of risks and benefits of corticosteroid injection, including but not limited to infection, bleeding, discomfort with injection, skin atrophy or color changes, injury to surrounding structures, elevated blood sugar, and the possibility of no improvement in pain symptoms patient gave verbal and written consent.
Time-out performed and site of injection was verified and patient identified by name and DOB.
Shoulder was prepped with betadine x 3. Ethyl chloride used for local anesthesia.
4 cc of 1% lidocaine and 40 mg of triamcinolone was mixed and then injected into the glenohumeral joint using a posterior approach with a 22 gauge needle.
Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if shoulder becomes warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
,.itbandSd
Pt c/o sharp and burning pain superior to right lateral knee. Radiates proximally to lateral thigh.
Denies injuries. Exercises frequently.
Workout includes biking and machine weights for legs. Worse at night after activities.
Similar episode a couple of years ago.
,.itbandSd#
# Insomnia CBT. Headspace app.
Reviewed cognitive and behavioral components including:
Sleep hygiene.
Establish bed and wake times.
Sleep restriction. (Only sleep estimated hrs sleep).
Bed only for sex and sleep, only sleep when sleepy, out of bed if anxious (stimulus control).
Reviewed relaxation techniques, mindful meditation.
Expected sleep duration. Addressed worries about not sleeping.
,.insomnia-f/u
Pt c/o persisting insomnia for >3mo.
No depression or anxiety.
No alcohol or tobacco.
Taking medication every night.
Reports improvement in number of hours and sleep quality.
methadone
Opioid use disorder On methadone. Compliant with program.
Denies any side effects like constipation, drowsiness, excessive sweating, swelling, reduced libido or erectile dysfunction.
Does not use any benzodiazepines or alcohol.
methadone#
# Interstitial cystitis Lifestyle changes. Pelvic physical therapy. Trial of amitriptyline.
erectile-dysfunction
Patient complains of difficulty obtaining/maintaining an erection. Denies any psychosocial stressors, psychosexual or relationship problems with partner.
Denies any excess alcohol intake.
232 statnote dot phrases - primary care phrase library
,.balanitis-bxo#
# Interstitial cystitis Lifestyle changes. Pelvic physical therapy. Trial of amitriptyline.
j.erectdle-dysfunction
Patient complains of difficulty obtaining/maintaining an erection. Denies any psychosocial stressors, psychosexual or relationship problems with partner.
Denies any excess alcohol intake.
232 statnote dot phrases - primary care phrase library
No history of diabetes, CAD or peripheral arterial disease. Patient does not smoke.
Denies any premature ejaculation.
Denies any genital pain or numbness.
Patient is not able to obtain erections when awakening.
erectile-dysfunction#
# Irritable bowel syndrome Constipation predominant.
With pain or bloating.
Discussed dietary modifications. Behavioral changes, decrease stress. Decrease caffeine, lactose and fructose.
Increase fiber intake in diet.
89 statnote dot phrases - primary care phrase library
Consider probiotics.
Trial of MiraLAX.
Dicyclomine 10 mg qid pm spasms. Consider SSRI, CBT.
,.ibs#diarrhea
# Irritable bowel syndrome Diarrhea predominant.
Loperamide prn diarrhea.
Discussed dietary modifications. Behavioral changes, decrease stress. Decrease caffeine, lactose and fructose.
Increase fiber intake in diet.
Consider probiotics.
Dicyclomine 10 mg qid prn spasms.
Consider SSRI, CBT.
,.lactose-intol
Pt c/o symptoms of abdominal pain, flatulence, and bloating after consuming dairy products.
No diarrhea.
,.lactose-intol#
# Keloid scar Silicone-based therapy.
Consider intralesional corticosteroid injection.
,.keloid-scar-PE
Smooth and shiny elevated scar with overhanging edge on _.
,.lichen-planus-PE
Purple planar patch on _
/
lichen-planus#
# Knee PFPS, right NSAIDs/tylenol prn.
Local analgesia with capsaicin topical. Quadriceps-strengthening exercises.
Knee brace.
Discussed wt loss.
Consider intra-articular corticosteroid injection.
,.knee-PE
Right Knee No effusion.
Normal gait.
crepitus.
Not TTP.
Full ROM and overall strength.
Normal patellar glide laxity.
Neg apprehension test.
Intact ligaments w/ valgus and varus stress; anterior and posterior drawer. Instability on single leg squad.
,.knee-asp/inj
Knee aspiration & injection, right
161 statnote dot phrases - primary care phrase library
After discussion of risks and benefits of aspiration and steroid injection, including but not limited to infection, bleeding, discomfort with injection, adverse reaction to protein and possibility of no improvement in pain symptoms patient gave verbal and written consent. Time-out performed and site of aspiration was verified and patient identified by name and DOB. Knee was prepped with betadine x 3. Ethyl chloride used for local anesthesia. 5 mL of lidocaine 1% with epinephrine were injected subcutaneously and into soft tissues, using a 25 gauge needle. Then using an 18 gauge needle using the inferolateral approach _60 mL of yellow cloudy fluid were aspirated. Subsequently 40 mg of triamcinolone mixed with 4 cc of l%lidocaine w/o epi was then injected. Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if knees become warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
knee-aspiration
Knee aspiration, right After discussion of risks and benefits of aspiration, including but not limited to infection, bleeding, discomfort with injection, and the possibility of no improvement in pain symptoms patient gave verbal and written consent. Time-out performed and site of aspiration was verified and patient identified by name and DOB. Knee was prepped with betadine x 3. Ethyl chloride used for local anesthesia. 5 mL of lidocaine 1% with epinephrine were injected subcutaneously and into soft tissues, using a 25 gauge needle. Then using an 18 gauge needle using the inferolateral approach _60 mL of yellow cloudy fluid were aspirated. Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if knees become warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
,.knee-inj
Knee steroid injection, right After discussion of risks and benefits of steroid injection, including but not limited to infection, bleeding, discomfort with injection, adverse reaction to
162 statnote dot phrases - primary care phrase library
protein, and possibility of no improvement in pain symptoms patient gave verbal and written consent. Time-out performed and site of injection was verified and patient identified by name and DOB. Knee was prepped with betadine x 3. Ethyl chloride used for local anesthesia. 40 mg of triamcinolone mixed with 4 cc of l%lidocaine w/o epi was then injected into knee using a 22 gauge needle using the inferolateral approach. Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if knees become warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
,.knee-inj*
20610
,.knee-inj-viscosuppl
Knee viscosupplementation injection, right After discussion of risks and benefits of hyaluronic acid injection, including but not limited to infection, bleeding, discomfort with injection, adverse reaction to protein, and possibility of no improvement in pain symptoms patient gave verbal and written consent. Time-out performed and site of injection was verified and patient identified by name and DOB. Right knee was prepped with betadine x 3. Ethyl chloride used for local anesthesia. 2.5 mL of hyaluronic acid _(Supartz) were then injected into knee using a 22 gauge needle using the inferolateral approach. Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if knees become warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
knee-meniscus
Pt c/o knee pain, right. Hx of knee trauma.
Knee swelling after trauma.
163 statnote dot phrases - primary care phrase library
Sensation of instability, buckling/catching.
knee-patellar-tendonitis
Pt c/o right knee pain, swelling and stiffness for a few weeks. Localized to anterior aspect.
Pt plays sports, frequent jumping.
No h/o previous injury.
,.knee-patellofem sd
Pt c/o knee pain, Right.
Insidious onset.
Ill-defined ache localized to the anterior knee.
Aggravated by climbing stairs., walking after prolonged sitting.
,.knee-OA
Knee osteoarthritis Pt c/o pain w/ activity & relieved by rest. Pain well controlled with NSAIDs.
,.knee-OA#
# LE edema Normal renal fx.
Gravity dependent.
Gecrease Na in diet.
Leg elevation and compression stockings recommended.
,.orthostadc-hypotension#
# Lactose intolerance Limit dairy products.
Consider lactase supplements.
Consider monitoring vit D if dairy intake is eliminated.
ulcerative-colitis
Ulcerative colitis On _. Compliant. No side effects.
90 statnote dot phrases - primary care phrase library
Denies any abdominal pain, diarrhea, or blood in the stools. No recent flares.
No arthropathies, cutaneous or ocular manifestations.
ulcerative-colitis#
# Latent TB + PPD/gold quant.
Not pregnant, HIV uninfected. Low-Incidence setting, r/o active TB: neg CXR, asymptomatic, no need for AFB sputum, monotherapy with rifampin x4 mo (lOmg/kg, max600).
monotherapy with isoniazid x6 mo (5mg/kg, max300).
Pyridoxine supplementation (25mg).
Baseline liver enzyme testing.
Monthly monitoring for hepatitis.
Discussed symptoms including anorexia, N/V, dark urine, ictericia, RUQ pain.
100 statnote dot phrases - primary care phrase library
,.tb-screen
Patient here for tuberculosis screening.
No history of previous positive PPD.
Denies being an immigrant from a high tuberculosis incidence country (Mexico, Philippines, Vietnam, India, China, Haiti, and Guatemala). Denies any close or casual contacts with active pulmonary/respiratory TB. Patient is not a healthcare worker nor has other occupations in which there is risk of exposure to patients with untreated contagious active TB (prison facilities, homeless shelters).
Patient denies having HIV infection.
Does not have a history of transplant, chemotherapy, or other major immunocompromising condition.
Patient denies having history of abnormal chest radiographs.
Patient does not take immunosuppressive medications or undergoing dialysis.
No history of diabetes or use of chronic glucocorticoids.
Not a cigarette smoker.
Denies any chronic cough or constitutional symptoms.
,.tb-screen#
# Lichen planus Clobetasol topical, taper down as soon as improving.
52 statnote dot phrases - primary care phrase library
Antihistamine pm itching.
melasma
Pt c/o dark spots on face.
No recent pregnancy.
Not on hormonal contraception.
sun exposure w/o photoprotection.
vmelasma#
# Lipoma Discussed treatment options.
Since lesion is bothersome and increasing in size. Patient opted for excision.
Lesion sent for pathology.
Wound care discussed with patient.
,.lipoma-PE
4x4 cm superficial mass, mobile, not tender to palpation.
248 statnote dot phrases - primary care phrase library
,.lipoma-excision
Lipoma excision Location: right _ Measuring _ cm Skin was cleaned with 70% alcohol swab.
Area was anesthetized with 1 % lidocaine.
Area was prepped in usual sterile fashion with 10% iodine swab and sterile drapes. Sterile gloves were used.
Linear excision performed on lesion with 15-blade.
Lesion removed excised blundy using small forceps and scissors. Hemostasis achieved.
Intermediate repair: layered closure of subcutaneous tissue using 4-0 vicryl, _ sutures placed.
Wound closed with 4-0 nylon suture, _ simple interrupted sutures placed. Triple antibiotic ointment and bandaid applied.
Specimen sent to pathology
,.pilonidal-abscess#
# Lower back pain Acute.
139 statnote dot phrases - primary care phrase library
W/o radiculopathy.
No red flags.
Tylenol or NSAIDS as first line tx.
Rx topicals: capsaicin, lidocaine.
Physical activity as tolerated, encouraged pt to stay active. Reassured pain will most likely resolve in a few weeks. Consider physical therapy.
Lifestyle modification: good lifting techniques.
Printed back exercises handout.
Short term use of muscle relaxant. Discouraged long-term use of opioids.
,.back-pam#chronic
# Lower back pain Chronic (>12wks).
W/o radiculopathy.
No red flags.
Tylenol or NSAIDS as first line tx.
Rx topicals: capsaicin, lidocaine.
Behavioral modification: wt loss.
Printed back exercises handout.
Consider Cymbalta.
Consider cognitive behavioral therapy.
Consider referral for pain management.
Discouraged long-term use of opioids.
Consider epidural steroid injection for chronic radicular pain from disk herniation.
,.back-pain#upp
# Lung nodule Detected during lung cancer screening.
Management according to Lung-RADS.
Category: 1 Continue annual screening with LDCT in 12 months.
,.pulmonaryHTN
Pulmonary hypertension Denies dyspnea or chest pain. No lower extremity swelling.
,.pulmonaryHTN #
# Lymphadenopathy, cervical .right Young pt (<50).
< 4 weeks , < 1 cm, localized.
Reassure, low-risk of malignancy.
If persisting for over a month or increasing in size consider work up. No need for bx at this point.
,.lymphadenopathy-PE
lxl cm nodular, non-tender, mobile mass on right cervical area.
93 statnote dot phrases - primary care phrase library
8 INFECTIOUS DISEASES
cellulitis
Pt c/o redness on skin.
Location: _ Present for days.
Became painful, redness worsening. No spontaneous drainage.
No fever or chills.
No h/o trauma or injury.
No history of bug bite.
cellulitis#
# Male hypogonadism 8-10 AM total testosterone.
If low (<300 ng/dL) consider repeat, including LH/FSH. Discussed affecting factors like weight and age.
,.osteoporosis
Osteoporosis Not taking medications.
No back pain.
Impaired gait, using a walker to ambulate. No recent falls.
71 statnote dot phrases - primary care phrase library
osteoporosis#
# Marijuana use DAST-10 score: 0 No problems related to drug abuse. Suggested action: None at this time. Structured screening/Counseling on adverse effects of cannabis use. Recommended cessation or cut down - 15 min.
1—2 Low level problems related to drug abuse. Suggested action: Monitor, re-assess at a later date.
3-5 Moderate level problems related to drug abuse. Suggested action: Further investigation.
6-8 Substantial level problems related to drug abuse. Suggested action:Intensive assessment.
9-10 Severe level problems related to drug abuse. Suggested action: Intensive assessment.
5 statnote dot phrases - primary care phrase library
morbid-obesity
Morbid Obesity Diet: high carbs.
Sugary drinks: occasional. Etoh: occasional. Sedentary lifestyle.
,.morbid-obesity#
# Melasma Trial of topical tx - modified Kligman formula. fluocinolone/hydroquinone/tretinoin topical (0.01%/4%/0.05%) qhs. Sun protection.
Discussed alternative options: chemical peels, dermabrasion, laser tx.
,.melasma-PE
Confluent irregularly shaped, brown to dark brown macules, symmetrically distributed on the face (forehead, malar).
,.mole
Concerned about skin lesion.
Location: left lower back.
Has noticed changes in lesion.
change in color.
increase in size.
itching.
No bleeding.
No family or personal history of skin cancer.
53 statnote dot phrases - primary care phrase library
onychomycosis
Patient complains of changes in toenails for years. Reports thickening and discoloration of toenails. Denies any toenail trauma.
Tried OTC treatment without improvement.
onychomycosis#
# Meniere disease Supportive therapy.
Rx meclizine, scopolamine, mild sedative. Salt restriction.
107 statnote dot phrases - primary care phrase library
,.dizziness#vestibular
# Menopause / hot flashes Failed non-hormonal therapies.
Starting HRT. Trial for 6 months. No longer than 10 years. Discussed benefits and risks. Pt demonstrate understanding. No contraindications. Low CVD risk score.
126 statnote dot phrases - primary care phrase library
,.menopause-HRT
Menopause Onset: less than 10 years.
Patient c/o hot flashes and night sweats.
Interfering with daily activities, bothersome.
Patient tried behavioral/lifestyle modifications for at least 3 months without adequate response.
Patient is interested in HRT.
Denies any vaginal bleeding.
No h/o liver disease, VTE, breast or endometrial cancer, CAD, CVA.
No first-degree family hx of breast cancer.
No hypertriglyceridemia.
No history of hysterectomy.
Patient does not smoke.
Not treated for HTN or DM.
vnexplanon-proc
Nexplanon insertion
Discussed contraceptive means available including 1UD, nuvaring, combination oral contraceptives, and Nexplanon.
She wishes to proceed with Nexplanon.
Urine HCG obtained and is **__N EG ATIVE__** Benefits and risks discussed with the patient.
Site: _left arm Sterile preparation with Betadine.
Insertion site was selected 10 cm from medial epicondyle and marked along with guiding site using sterile marker.
Procedure area was prepped and draped in a sterile fashion. 5 mL of 2% lidocaine without epinephrine used for subcutaneous anesthesia. Anesthesia confirmed.
Nexplanon trocar was inserted subcutaneously and then Nexplanon capsule delivered subcutaneously.
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Trocar was removed from the insertion site.
Nexplanon capsule was palpated by provider and patient to assure satisfactory placement.
Estimated blood loss: minimal.
Dressings applied: Adhesive Dressing.
Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.
,.nexplanon*J
J7307
,. nexplanon-ins er tion*
11981
,.nexplanon-removal-reins*
11983
,. nexplanon-removal*
11982
,.nst/afi
# Menopause / hot flashes Trial of non-hormonal therapies. Black cohosh/soy isoflavones. Consider paroxetine or venlafaxine.
infertility
Infertility'
123 statnote dot phrases - primary care phrase library
Reports inability to conceive for more than 12 months of frequent unprotected intercourse.
Regular menstrual periods.
No h/o oligo/amenorrhea.
No h/o STDs or suspected tubal disease/endometriosis.
No h/o chemo or radiotherapy.
Male partner has not undergone semen analysis.
infertility#
# Menopause / hot flashes Trial of non-hormonal therapies. Black cohosh/soy isoflavones. Consider paroxetine or venlafaxine.
,.menopause#HRT
# Metatarsalgia Conservative management. Analgesics pm.
Metatarsal pads.
,.foot-pain-PE
Hammer toes.
Splayed toes.
Interphalangeal toes flexion contractures.
Calluses on the dorsum of proximal interphalangeal joints. Calluses over the plantar metatarsophalangeal joints.
152 statnote dot phrases - primaiy care phrase library
,.ganglion-cyst
Pt c/o mass on wrist.
Reports some pain.
Increases in size after activity. Denies any numbness of fingers.
, .ganglion-cy s t#
# Migraine headache w/o aura Controlled w/ abortive treatment prn.
No need for preventive treatment at this point. Discussed trigger avoidance and behavioral modification, (sleep, regular meals, hydrations, regular exercise).
,.ms#
# Mild cognitive impairment Stable.
No depression.
Good community support. Recommended physical activity/exercise.
,.mci-f/u
Mild cognitive impairment No significant decline since last visit.
No significant changes in memory, forgetfulness. No new medications or recent acute illness.
No depression.
109 statnote dot phrases - primary care phrase library
Still able to manage finances.
No problems with language/word finding. Not getting lost in familiar places.
No behavior problems.
migraine
Migraine headaches Migraine episodes unchanged. On Imitrex pm.
Avoids triggers.
Effects on daily activities: decreased activity level.
Interfering w/ daily activities at school/work/home.
Interfering w/ sleep.
Associated symptoms: aura, sensitivity to light, visual disturbance, N/V.
migraine#
# Morbid Obesity Discussed appropriate BMI.
Goal of losing 1 lb per month.
Diet modification.
Physical activity.
Encouraged/praised to build confidence.
naloxone
Naloxone rx sent. Concurrent use of opiates with benzodiazepines.
A prescription for naloxone intranasal kit was sent to the patient’s pharmacy. Patient was educated on when and how to administer naloxone intranasal. Patient was provided with our clinic handout on naloxone administration. I have also advised the patient to share this information with friends, family, and other members of their household and offered patient the option to help train any said individuals if they so desire.
,.obesity
Obesity
Diet: high carbs.
Sugary drinks: occasional. Etoh: occasional. Sedentary lifestyle.
6 statnote dot phrases - primary care phrase library
,.obesity#
# Morton neuroma Conservative management.
Wide toe-box shoes and Metatarsal pad recommended.
,.morton-neuroma-PE
Positive Mulder sign on 3-4 toe web space.
neck-pain
Pt c/o neck pain x days.
No radiation.
Pain described as sharp.
Exacerbated by neck rotation.
Relieved by rest.
No assoc sx like: weakness, decreased sensation, dropping objects. No history of steroid use, malignancy, infection, depression. Denies any recent trauma or occupational injury.
neck-pain#
# Mucocele Of lower lip.
Drainage and cryotherapy done.
Postprocedure care: pressure for the next hour.
Topical antibiotic ointment to avoid irritation/infection. Pain control as needed with OTC meds.
Healing expected within 1-2 wks.
,.mucocele*cryo
40820
,.mucocele*drain
40810
,.mucocele-PE
Left lower lip: 7x7 mm nontender, mobile, dome-shaped enlargement with intact epithelium that lies over it. Translucent.
,.mucocele-proc
Procedure: Mucocele destruction Indication: Lower lip mucocele.
Consent: A consent form was signed and witnessed after a discussion with the patient/guardian of the risks (including but not limited to pain, bleeding, infection, scar formation, slow healing, recurrence of lesion, and failure to diagnose more serious pathology), benefits (treatment of lesion).
80 statnote dot phrases - primary care phrase library
and alternatives (including but not limited to simple aspiration, excision, and watchful waiting).
Technique: The mucosa surrounding the lesion was cleansed with Betadine and then anesthetized with lidocaine 1% with epinephrine 1 :100,000 through a 30-gauge needle, using a total volume of 3 mL. Anesthesia was confirmed. A small stab wound was made in the cyst laterally using an 11 blade, and the seromucinous contents were expressed.
The lesion was frozen with liquid nitrogen with a 2-mm rim of normal tissue included for 5 seconds. Final hemostasis was achieved with brief application of electrocautery to any visible areas of bleeding. Antibiotic ointment was applied to the lesion.
Complications: None Estimated blood loss: Less than 5 mL Follow-up: If needed for any signs or symptoms of infection or recurrence of lesion.
OtltlS
C/o _ ear pain x days.
No fever or chills.
Denies any otorrhea.
No headache, pain over mastoid area, neck pain or photophobia No recent URI sx or sinus infx No h/o previous OM.
otitis#
# Mucocele Of lower lip.
Drainage and cryotherapy done.
Postprocedure care: pressure for the next hour.
Topical antibiotic ointment to avoid irritation/infection. Pain control as needed with OTC meds.
Healing expected within 1-2 wks.
,.mucocele*cryo
40820
,.mucocele*drain
40810
,.mucocele-PE
Left lower lip: 7x7 mm nontender, mobile, dome-shaped enlargement with intact epithelium that lies over it. Translucent.
,.mucocele-proc
Procedure: Mucocele destruction Indication: Lower lip mucocele.
Consent: A consent form was signed and witnessed after a discussion with the patient/guardian of the risks (including but not limited to pain, bleeding, infection, scar formation, slow healing, recurrence of lesion, and failure to diagnose more serious pathology), benefits (treatment of lesion).
80 statnote dot phrases - primary care phrase library
and alternatives (including but not limited to simple aspiration, excision, and watchful waiting).
Technique: The mucosa surrounding the lesion was cleansed with Betadine and then anesthetized with lidocaine 1% with epinephrine 1 :100,000 through a 30-gauge needle, using a total volume of 3 mL. Anesthesia was confirmed. A small stab wound was made in the cyst laterally using an 11 blade, and the seromucinous contents were expressed.
The lesion was frozen with liquid nitrogen with a 2-mm rim of normal tissue included for 5 seconds. Final hemostasis was achieved with brief application of electrocautery to any visible areas of bleeding. Antibiotic ointment was applied to the lesion.
Complications: None Estimated blood loss: Less than 5 mL Follow-up: If needed for any signs or symptoms of infection or recurrence of lesion.
,.OtltlS
C/o _ ear pain x days.
No fever or chills.
Denies any otorrhea.
No headache, pain over mastoid area, neck pain or photophobia No recent URI sx or sinus infx No h/o previous OM.
otitis#
# Multiple sclerosis Stable.
MR1 done <1 yr ago.
Fatigue w/u: vit D/B12, thyroid.
Recommended regular exercise, sleep hygiene, and low-fat diet. Mind-body therapy: yoga, relaxation.
Optimal control of chronic conditions.
110 statnote dot phrases - primary care phrase library
,.ms-hpi
Multiple sclerosis No recent relapses.
Motor symptoms: leg weakness, problems ambulating. No spasms. Sensory symptoms: pain and dysesthesia.
No urinary symptoms.
No visual impairment.
No fatigue.
On no meds.
occipital-neuralgia
Pt c/o sudden onset headache that starts in the neck and radiates to the vertex area/eye.
Right sided. Described as stabbing pain with persistent aching between paroxysms.
Pain is debilitating. Minimal improvement with NSAIDs/tylenol.
occipital-neuralgia#
# NST/AFI TOCO: none.
NST: baseline 150, mod variability, accels, no decels . cat 1. AFI 9.56 NST/AFI f/u.
128 statnote dot phrases - primary care phrase library
,.pcos
PCOS Pt is obese.
No hirsutism.
Irregular menstrual periods. + infertility.
,.pcos#
# Neck/upper back pain W/o radiculopathy.
No red flags.
165 statnote dot phrases - primary care phrase library
Tylenol or NSAIDS as first line tx. Rx topicals: capsaicin, lidocaine. Consider physical therapy.
Printed exercises handout.
,.neck-pain-PE
Bilateral upper back /neck tender to palpation on trapezius muscle area. Negative Spurling’s test.
olecranon-bursitis
Pt c/o pain and swelling on right elbow, at site of bursa. Denies any recent trauma.
Denies any fevers or chills.
olecranon-bursitis#
# OSA on CPAP Good compliance. Symptoms improved. Continue to monitor.
paraplegia
Paraplegic 2/2 spinal cord injury, wheelchair bound. Wife is primary caregiver.
Neurogenic bowel Having regular bowel movements w/ current bowel regimen. Neurogenic bladder Self cath q6hrs.
No recent symptoms of autonomic dysreflexia.
No pressure ulcers noted by patient or caregiver.
Spasticity well control with current dose of baclofen.
112 statnote dot phrases - primary care phrase library
,.paraplegia#
# Obesity
Discussed appropriate BMI.
Goal of losing 1 lb per month.
Diet modification.
Physical activity.
Encouraged/praised to build confidence.
opioids
Combined use of opioids and benzodiazepines increases the risk of extreme sleepiness, respiratory depression, coma and death. Please avoid using them at the same time. Patient expressed understanding.
,.osa-screen
OSA screen Pt snores loudly + Feels tired, fatigued, or sleepy during daytime + Observed stop breathing during sleep + H/o HTN + BMI >35 + Age >50 + Neck circumference >16" + Male +
,.osa-screen#
# Occipital neuralgia Recommended conservative tx.
Application of local heat/cold to alleviate muscle spasm/pain. Consider local occipital nerve block to alleviate the pain.
occipital-neuralgia-in j
Occipital neuralgia injection Location: bilateral suboccipital region.
Injection: 40 mg of triamcinolone + 1 mL of 1% lidocaine using a 25 G 1 in needle, on ea site.
Entry point was marked.
Area was prepped in the usual sterile manner.
The needle was inserted into the affected area and the steroid was injected.
Ill statnote dot phrases - primary care phrase library
Patient tolerated procedure well without complications.
Standard post-procedure care was explained and return precautions given.
occipital-neuralgia-inj*
64405
,.osa-on-cpap
OSA on CPAP Good adherence to CPAP use.
Comfortable with CPAP pressures and mask fit. Reports improvement in alertness and quality of life.
,.osa-on-cpap#
# Olecranon bursitis Conservative management and analgesia. Rest + Ice + Compression.
Consider steroid injection.
,.olecranon-bursitis-PE
Right elbow with edema and erythema at the site of bursa. Warm to touch and tender to palpation.
,.olecranon-bursitis-inj/ asp
Olecranon bursitis aspiration and injection, right
166 statnote dot phrases - primary care phrase library
Elbow was marked and then prepped in the usual sterile fashion. Using a 20 gauge 1.5 inch needle, _5 ml of serosanguineous fluid was aspirated from the joint space without difficulty. A mixture of 2 cc of 1% lidocaine and 20 mg of triamcinolone were then injected. After aspiration and injection, the joint was passively moved through the full range of motion and a sterile dressing was applied. The patient tolerated the procedure well. Aftercare discussed.
,.olecranon-bursitis-inj/ asp*
20605
patellar-bursitis
Pt c/o anterior knee pain.
No swelling or redness.
Worsens w/ kneeling. Relief w/ rest. Occupation requiring excessive kneeling.
,.pes-anserine*
20605
,.pes-anserine-inj
Pes anserine injection, right After discussion of risks and benefits of steroid injection, including but not limited to infection, bleeding, discomfort with injection, adverse reaction to protein, and possibility of no improvement in pain symptoms patient gave verbal and written consent. Time-out performed and site of injection was verified and patient identified by name and DOB. Knee was prepped with isopropyl alcohol x 3. Ethyl chloride used for local anesthesia. 20 mg of kenalog mixed with 1 cc of l%lidocaine w/o epi was then injected into pes anserine bursa/point of maximal tenderness using a 25 gauge needle.
167 statnote dot phrases - primary care phrase library
Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if knees become warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
,.pes-planus
Flat feet, bilateral Pt c/o pain and swelling in the medial ankle and midfoot during weight bearing.
Condition present for years.
,.pes-planus#
# Onychomycosis Confirmed diagnosis with microscopic test. Start terbinafine.
Send patient for liver function tests.
,.onychomycosis#f/u
# Onychomycosis Did not achieve complete resolution with po meds. Trial of topical ciclopirox.
,.onychomycosis-PE
Multiple toenails with marked nail thickening, yellowish nail discoloration, onycholysis, and subungual debris.
paronychia
Paronychia Patient c/o pain, tenderness, and swelling in lateral fold of nail of _
,.paronychia#
# Onychorrhexis Recommended nail varnish.
Avoid humidity/prolonged exposure to water.
,.fragile-nails-PE
Longitudinal nail grooves with distal splits affecting all nails.
,.granuloma-annulare
Hand: annular nonscaly reddish-brown plaque. Plaque centers are hypopigmented relative to the edges.
49 statnote dot phrases - primary care phrase library
, .granuloma-annulare#
# Opioid use disorder On buprenorphine. Stable.
Continue current management per psych.
suicide-contract
No-suicide agreement. Pt promises not to do anything to harm or kill herself.
Will contact 911 or go to ED if having suicidal thoughts.
Other resources discussed:
National Suicide Prevention Lifeline - Call 1-800-273-8255 (Available 24 hours everyday).
Lifeline Chat - https://suicidepreventionlifeline.org/chat/
225 statnote dot phrases - primary care phrase library
14 PULMONOLOGY
asthma
Asthma On albuterol and Qvar.
SOB/wheezing/use of SABA < 2/week.
Night symptoms < 2/month.
No activity limits.
No hospitalizations for exacerbations during the last year.
asthma#
# Opioid use disorder On buprenorphine. Stable.
Continue current management per psych.
,.bulimia#
# Opioid use disorder On methadone. Stable. F/u at methadone clinic.
224 statnote dot phrases - primary care phrase library
psychotherapy#
Time spent doing psychotherapy exclusive of E/M time: 16 minutes. Psychotherapy intervention used: Supportive Psychotherapy.
,.psychotx*
90833
suboxone
Opioid use disorder On Suboxone.
Denies any side effects like sedation, headaches, nausea, constipation or insomnia.
Does not use any benzodiazepines or alcohol.
suboxone#
# Oral candidiasis/ thrush Topical antifungal.
Aggressive disinfection of removable dentures.
,.thrush-PE
Creamy white plaque fairly adherent to oral mucosa/tongue.
tinnitus
Pt c/o episodic pulsatile sounds for the last few months. Denies any hearing loss or dizziness.
Denies hx of noise exposure.
Denies visual changes.
tinnitus#
# Orthostatic hypotension Recommended adequate hydration, compression stockings, sitting before standing.
,.pad#
# Osteoporosis No h/o osteoporosis fractures, not a high-risk patient. Recent Dexa scan T-score >-3.5.
Bisphosphonate for <5 years.
Discussed the risks/benefits of therapy.
,.vit-d-def
Pt wants to be screened for vit D deficiency.
C/o fatigue.
Denies any muscle weakness.
No h/o CKD.
Denies inadequate sunlight exposure.
Reports having a good diet, including dairy products.
No h/o IBDs, celiac, CF, or surgeries causing malabsorption. Pt is obese.
,.vit-d-def#
# Otitis externa Start Ciprodex.
NSAIDs for pain control.
,.otitis-externa-PE
Right ear with external canal edema and purulence. + tragal tenderness. No mastoid tenderness.
pterygium
Pterygium Pt c/o ocular irritation, burning and tearing Noticed conjunctival lesion on _right eye.
Hx of chronic UV light exposure.
Denies any blurred vision or any other vision disturbance.
pterygium#
# Otitis externa Start Ciprodex.
NSAIDs for pain control.
,.otitis-externa-PE
Right ear with external canal edema and purulence. + tragal tenderness. No mastoid tenderness.
pterygium
Pterygium Pt c/o ocular irritation, burning and tearing Noticed conjunctival lesion on _right eye.
Hx of chronic UV light exposure.
Denies any blurred vision or any other vision disturbance.
pterygium#
# Overactive bladder Behavioral approaches + lifestyle changes.
Kegel exercises.
Caffeine reduction, fluid management/reduction.
Trial of antimuscarinics (oxybutynin).Ddiscussed side effects.
overactive-bladder
Pt c/o leaking urine when having a strong urge on the way to the bathroom.
Endorses urinary frequency.
Urge to urinate is waking up pt and interfering with sleep.
Has to wear pads for protection.
overactive-bladder#
# Overactive bladder Behavioral approaches + lifestyle changes.
Kegel exercises.
Caffeine reduction, fluid management/reduction.
trial of antimuscarinics (oxybutynin). discussed side effects.
234 statnote dot phrases - primary care phrase library
phimosis
C/o penile partial phimosis. Some itching.
No painful erections or urination. No urinary obstruction.
phimosis#
# Overweight Discussed appropriate BMI.
Goal of losing 1 lb per month.
Diet modification.
Physical activity.
Encouraged/praised to build confidence.
preop#
Preop eval Presently Clinically Stable for Scheduled Surgery.
Avoidance of Aspirin or IS!SAIDS 5-7 days prior to surgery.
To call with any changes in present status.
EKG: NSR, no significant issues noted.
Labs: sent for routine preop labs and CXR.
No contraindication to surgery if normal laboratory and imaging studies.
,.preop-eval
Here for pre-op eval. Surgeon:
8 statnote dot phrases - primary care phrase library
Date Of Surgery:
Diagnosis:
Procedure:
No complications from previous anesthesia.
Pt has no active cardiac conditions.
No h/o CAD or prior MI.
No h/o CHF.
No h/o DM, insulin dependent.
No h/o CKD on HD.
Good functional status. Pt is able to walk four blocks or climb two flights of stairs.
Patient denies CP, SOB, or palpitations during the last six months.
stable
Stable. No changes in management.
tobacco#
# PCOS With infertility and desiring fertility. Weight loss.
Trial of metformin.
pelvic-organ-prolapse
Pt c/o sensation of vaginal pressure. Denies any vaginal protrusion/bulge. H/o vaginal deliveries.
Denies urinary incontinence, reports urinary retention.
pelvic pain.
C/o sexual dysfunction/dyspareunia.
pelvic-organ-prolapse#
# PID Ceftriaxone 250 IM given.
Rx doxycycline 100 mg po bid x 14 days.
Sent GC/CT.
Return if symptoms fail to improve or worsen.
,.plan-b
Pt requesting emergency contraception.
She had unprotected vaginal intercourse and wishes to reduce her risk of pregnancy.
Intercourse <5 days ago.
Requesting oral med (plan B).
LMP: wks ago.
,.plan-b#
# Para/Quadri plegic 2/2 spinal cord injury after _.
Stable.
Continue self-cath and bowel regimen for neurogenic bladder/bowel. No episodes of autonomic dysreflexia.
No skin lesions. Monitor. Continue frequent repositioning, f/u at _.
115 statnote dot phrases - primary care phrase library
v syncope
Syncope Patient reports abrupt, brief, total LOC & postural tone with spontaneous recovery. Denies any postictal symptoms.
Denies prior episodes.
Situation: Pt was _ at time of event.
Provocative factors: exertion, changing position, eating, coughing, sneezing, swallowing, anxiety, pain, defecation/micturition.
Associated symptoms: Denies CP, dyspnea, palpitations.
Pt is amnestic to events.
Event was not witnessed.
Denies any recent changes in medications.
Denies family history of cardiac ds or sudden cardiac death.
syncope#
# Paraplegia 2/2 spinal cord injury Stable. Continue bowel regimen, self-cath and baclofen. Monitor for pressure ulcers, autonomic dysreflexia. Spasticity well controlled. Continue current dose of baclofen.
parkinson
Pt c/o resting tremor of upper limbs. Rigid and slow movements.
No recent falls.
No memory problems.
No fatigue.
No depression.
parkinson#
# Parkinson ds Trial of carbidopa/levodopa 50 mg tid. titrate according to response. Recommended physical activity, tai-chi.
,.parkinson-PE
Masked facies, resting tremor of upper extremities, rigidity, cogwheeling noted. Micrographia. Shuffling gait.
,.quadriplegia
Here accompanied by caregiver _.
Quadriplegia d/1 spinal cord injury at _ level after _ years ago.
Pt is wheelchair bound.
Neurogenic bladder. Pt does intermittent self cath q4h. No recent UTIs. Neurogenic bowel. Compliant with bowel regimen.
113 statnote dot phrases - primary care phrase library
No reported episodes of autonomic dysreflexia. No reported skin lesions.
Pt is being followed at __. By Dr. __.
No changes in management during last visit.
,.quadriplegia#
# Paronychia
54 statnote dot phrases - primary care phrase library
With abscess. Incision and drainage performed. Started amoxicillin/clavulanate 875/125 po bid. Daily wound care.
paronychia*
10060
,.paronychia-PE
_ erythema and pus surrounding nail fold. Tender and fluctuant to palpation.
,.paronychia-proc
Paronychia with abscess I&D Location: right _ Consent obtained.
Local anesthesia achieved with ethyl chloride. Area cleaned with alcohol. Puncture incision made with 18 G needle inserted under the affected cuticle margin. Small amount of white thick material was expressed.
Hemostasis achieved with compression.
Wound dressed with dry, sterile dressing. Pt tolerated procedure well.
,.penile-sebaceous-h
Pt c/o whitish lesion on scrotum and penis. No new sexual contacts.
No dysuria or penile discharge.
Lesion is not painful.
Present for months.
55 statnote dot phrases - primary care phrase library
,.penile-sebaceous-h#
# Pearly penile papules Reassured pt.
No tx needed.
Consider laser therapy for cosmetic concerns.
235 statnote dot phrases - primary care phrase libraiy
,.ppp-PE
GU: multiple skin-colored, semi-transparent elevated papules arranged in rows on the coronal ring.
stress-incontinence
Pt c/o involuntary urine leakage on effort, exertion, sneezing/coughing. Accompanied by urgency.
Denies any vaginal bulge/pressure sensation.
H/o 3 vaginal deliveries.
stress-incontinence#
# Pelvic organ prolapse Symptomatic.
Discussed conservative tx w/ vaginal pessaries. As well as surgical repair options.
129 statnote dot phrases - primary care phrase library
,.pid#
# Penile sebaceous hyperplasia Reassured pt.
Consider cryotherapy if bothersome.
,.penile-sebaceous-h-PE
Smooth white colored papules on shaft of penis and scrotum, not tender to palpation.
psoriasis
C/o white spots on skin.
Present for several months.
Affecting trunk and scalp.
Denies any nail involvement or joint pain.
psoriasis#
# Pes planus, bilateral XR ordered.
Conservative management.
NSAIDs prn.
Consider use of orthotics.
Appreciate podiatry consultation and recommendations.
,.pes-planus-PE
Bilateral visible pes planus deformity.
Inability/ pain upon attempts to perform a single-leg heel rise. Abnormal wear of the medial heel and inner border of footwear noted.
,.piriformis-sd
Patient c/o right buttock pain that radiates to leg. No h/o trauma or injury.
Worsens with sitting.
168 statnote dot phrases - primary care phrase library
,.piriformis-sd#
# Phimosis Partial.
Not compromising voiding or sexual function. Consider circumcision.
ED precautions with paraphimosis.
,.phimosis-PE
Penile foreskin with ring atrophy and hypopigmented skin lesion, difficult retraction of glans.
vPPP-hpi
Pt c/o penile lesions at the tip of his penis. Present for months.
No new sexual partners.
,-ppp#
# Pilonidal disease Asymptomatic.
Hair removal + local hygiene.
,.pilonidal-ds-PE
Sinus tract in the sacrococcygeal region, surrounding erythema, warmth, tenderness and fluctuance.
post-op-visit*
99024
sebaceous-cyst
Pt complains of cystic mass on _ Present for many months. Increasing in size.
Some pain and tenderness.
sebaceous-cyst#
# Pilonidal disease With abscess.
I&D performed.
Healing by secondary intention. Abx: Bactrim.
Analgesics.
,.pilonidal-ds
Pt c/o tailbone pain and swelling, worse when sitting. Had some discharge.
Observed sinus tracts around the area.
249 statnote dot phrases - primary care phrase library
,.pilonidal-ds#
# Piriformis syndrome Physical therapy involving strengthening of the pelvic and hip region and stretching of the piriformis. Prn analgesics.
Consider steroid injection if not improving.
,.piriformis-sd-PE
Abnormally tight and tender piriformis muscle on right buttock and positive figure-four test. Pain also reproduced with resisting external rotation.
,.piriformis-sd-inj
Injection piriformis sd, right Piriformis muscle was located about half the distance from the sacral crest to the femoral trochanter.
Maximal point of tenderness was identified and entry point was marked. Area was prepped in the usual sterile manner.
Injection: 40 mg of triamcinolone + 1 mL of 1% lidocaine using a 25 G 1 in needle.
The needle was inserted into the affected area and the steroid was injected. Patient tolerated procedure well without complications.
Standard post-procedure care was explained and return precautions given.
vpiriformis-sd-inj*
20552
,.plantar-fasciitis
Patient complains of heel pain, right Described as stabbing.
169 statnote dot phrases - primary care phrase library
Pain exacerbated by walking barefoot.
Relieved with rest.
Pain with the first few steps after rising from a seated or lying position. No improvement with NSAIDs.
,.plantar-fasciitis#
# Plantar fasciitis Rest.
Weight loss.
Stretching exercises.
Foot orthotics and night splint.
Consider steroid injection if not improving.
,.plantar-fasciitis*strapping
29540
,.plantar-fasciitis-PE
left foot: no tenderness to palpation on plantar medial arch, distal to insertion of calcaneus.
,.plantar-fasciitis-inj *
20550
plantar-fasciitis-inj
Plantar Fascia Injection, Right Informed consent was obtained from the patient. Special mention was made of the possibility of heel pad atrophy and plantar fascia rupture. The
170 statnote dot phrases - primary care phrase library
patient was placed in the supine position. The tender area in the medial aspect of the heel was identified by palpation. After proper preparation of the skin with antiseptic solution skin, a syringe containing 1 mL of 1% lidocaine and 40 mg of triamcinolone was attached to 1.5” 25 gauge needle. The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus. The solution was injected as a bolus at the origin of the plantar fascia. The contents of the syringe were then gently injected and flowed smoothly into the space. Subsequently the needle was removed. Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.
POST PROCEDURE INSTRUCTIONS: The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the extremity for the next 24 hours.
,.ra-hands
Pt c/o bilateral hand joint pain and swelling. Reports morning stiffness.
Fam hx of rheumatoid arthritis.
,.ra-hands#
# Plantar wart Cryotherapy done. Salicylic acid gel.
,.wart-plantar-PE
Left plantar foot: hyperkeratotic, skin-colored papule with tiny black dots in the lesion, overlying callus.
68 statnote dot phrases - primary care phrase library
4 ENDOCRINOLOGY
,.acanthosis-nigricans-PE
Symmetric, dark brown hyperpigmented plaques with a velvety appearance on neck folds, axillae and inframammary folds.
,.dm2#
# Postpartum D/c prenatal vitamins.
Discussed symptoms of postpartum depression. Contraception: _ Follow up prn.
,.pregnancy
Here for pregnancy test.
LMP: 1/10/16 ICON + Planned pregnancy, was not using any contraceptive. Pt isGIPl Had a NSVD 4 yrs ago, no perinatal complications.
131 statnote dot phrases - primary care phrase library
No fam hx of congenital problems.
Wishes to establish prenatal care here.
Pt does not smoking, drinking, or using any drugs. Lives at home w/ husband and daughter.
Feels safe at home.
pregnancy#
# Pregnancy G2P1 @ 6W1D.
EDD 10/16/16 by LMP.
Counseled on nutrition and wt gain.
Rx prenatal MV.
Sent for OB panel, HIV, and U.Cx Vaginal bleeding, and spontaneous abortion signs and symptoms reviewed, if present go to hospital OB intake done by nurse.
Nurse will call back for initial OB visit appt.
prenatal
Here for prenatal care. No VB or UC.
FM.
FHT.
See ACOG.
prenatal# 1
# Premenstrual Syndrome Mixed somatic and behavioral symptoms.
Trial of oral contraceptives.
Lifestyle modification. Exercise, relaxation, and CBT. Consider SSR1 if not improving.
postpartum
The patient had a vaginal delivery on _ and is _ weeks postpartum. Type of laceration or episiotomy: _ Lochia: + Difficulty with urination: no.
Difficulty with hemorrhoids: no.
No difficulties breastfeeding.
Denies feeling depressed or difficulties handling the baby.
Desires contraception.
,.postpartum#
# Prenatal care G1P0 w/ 1UP @13 wks 3 d. Counseled on nutrition and wt gain. OB panel utd.
MSAFP#1 done (10-13).
Nuchal US done (10-13).
132 statnote dot phrases - primary care phrase library
Vaginal bleeding, and spontaneous abortion signs and symptoms reviewed, if present go to hospital, f/u in 4 wks.
,.prenatal#2
# Prenatal care G1P0 w/ IUP @ 28 wks 3 d.
Counseled on nutrition and wt gain.
Vaginal bleeding, and spontaneous abortion signs and symptoms reviewed, if present go to hospital.
US anatomy screen done.
MSAFP #2 done (16-20).
F/u in 4 wks.
,.prenatal#2.1
# Prenatal care G1P0 w/ IUP @ 34 wks 3 d.
Counseled on nutrition and wt gain.
Preterm labor signs and symptoms reviewed, if present go to hospital. FM/kick counting if decreased fetal movement.
Breastfeeding class.
Hospital registration (32).
F/u in 2 wks.
,.prenatal#3
# Prenatal care G1P0 w/ IUP @ 36 wks 3 d.
Counseled on nutrition and wt gain.
Preterm labor signs and symptoms reviewed, if present go to hospital. FM/kick counting if decreased fetal movement.
GBS done (35-37).
Hospital registration (32).
133 statnote dot phrases - primary care phrase library
Carseat.
F/u in 2 wks.
,.vaginal-atrophy
Vaginal atrophy C/o painful intercourse, dryness, itchiness. No vaginal bleeding.
, .vaginal-atrophy#
# Psoriasis Moderate, affecting >3% body surface area. Affecting nails.
Started topical treatment.
Clobetasol and triamcinolone for intertriginous areas. Calcipotriene.
Neutrogena T/Sal shampoo.
Consider systemic tx. Referral to rheumatology.
,.psoriasis-PE
f
Sharply demarcated erythematous, silver scale plaques of the scalp, elbows and knees, neck/chest.
Axillae and groin also involved.
)
56 statnote dot phrases - primary care phrase library
Nail pitting observed.
,.punch-bx
Punch Biopsy of _Left leg lesion.
Skin cleaned with 70% alcohol swab.
Area anesthetized with 1% Lidocaine without epi.
Area was prepped in usual sterile fashion with 10% Iodine swab and sterile drapes, and sterile gloves used.
Using a _5 mm circular Punch device, downward pressure was applied to obtain a cylindrical core of tissue.
Tissue specimen removed easily with Iris scissors and Adson forceps. Wound closed w/ 4-0 Nylon suture. 2 simple interrupted sutures placed. Hemostasis achieved.
Triple antibiotic ointment and bandaid applied.
Specimen sent to pathology.
,.punch-bx-l*
11104
,.punch-bx-2+*
11105
,.rash
C/o rash Involving face, scalp ,mouth, trunk, extremities, diaper area, flexure area. Has been present for days, worsening.
Spread to _ from initial area.
Not pruritic.
Not associated w/ fever, arthralgias, URI symptoms, or other recent viral syndromes.
57 statnote dot phrases - primary care phrase library
Interventions to date: OTC hydrocortisone cream, non responsive. Precipitating factors:
No new medications.
Denies any insect bites.
rosacea
Rosacea C/o redness and flushing of central face. Worsens with certain foods.
No ocular involvement.
rosacea#
# Pterygium Bilateral.
Causing irritation. - trial of artificial tears. Not causing visual impairment.
UV light protection.
82 statnote dot phrases - primary care phrase library
Right paraspinal area tender to palpation. Full ROM.
,.back-PE-upp
Upper back: no obvious deformities.
Right trap area tender to palpation. Neck full ROM.
back-pain-low
C/o lower back pain x days.
No radiation.
Pain described as sharp.
Exacerbated by bending.
Relieved by rest.
No assoc sx like: fever, bowel/bladder incontinence, and neurologic deficits, saddle anesthesia.
No history of steroid use, malignancy, infection, depression.
Denies any recent trauma or occupational injury.
,.back-pain-upp
C/o neck pain x days.
No radiation.
Pain described as sharp.
Exacerbated by neck rotation.
Relieved by rest.
No assoc sx like: weakness, decreased sensation, dropping objects. No history of steroid use, malignancy, infection, depression. Denies any recent trauma or occupational injury.
,.back-pain#acute
# Pterygium Bilateral.
Causing irritation. - trial of artificial tears. Not causing visual impairment.
UV light protection.
82 statnote dot phrases - primary care phrase library
Consider referral to ophthalmology if not improving.
,.pterygium-PE
Eyes, bilateral: wing-shaped conjunctival overgrowth onto the corneal surface. Nasal side. Not crossing the midline.
sialadenitis
Pt c/o of facial swelling and pain.
No dysphagia.
Similar previous episode.
No fever or chills.
Denies any pus coming from salivary gland opening. Not taking anticholinergic medications.
sialadenitis#
# Pulmonary hypertension WHO class Ill, d/t lung ds and hypoxia. Asymptomatic w/ ordinary activity.
EF __60-65% (__2013) On ASA. no need for further anticoagulation. Stable, monitor.
229 statnote dot phrases - primary care phrase library
15 RENAL/UROLOGY
balanitis
Pt c/o pain at the tip of penis. Some difficulty urinating/dysuria. No itch or penile discharge.
No new partners.
No h/o penile trauma.
No fevers or chills.
balanitis#
# Quadriplegic 2/2 spinal cord injury after _.
Stable.
Continue self-cath and bowel regimen for neurogenic bladder/bowel. No episodes of autonomic dysreflexia.
No skin lesions. Monitor. Continue frequent repositioning, f/u at
,.rls-hpi
Pt c/o dysesthesias described as tingling, cramping and aching of the lower extremities.
Symptoms usually worsen later in the day, often in the hours preceding sleep.
Symptoms decrease momentarily with movement, stretching or massage.
,.rls#
# Renal colic Recommended hydration, pain control, and prn zofran. Labs: BMP check renal fx.
UA to check for blood r/o infx.
Medical expulsive therapy with tamsulosin.
Renal US to confirm dx of nephrolithiasis.
If >10 mm or failing med tx refer to urology for sx removal.
,.nephrolithiasis-PE
CVA/flank tenderness.
233 statnote dot phrases - primary care phrase library
,.oab-hpi
Pt c/o leaking urine when having a strong urge on the way to the bathroom.
Endorses urinary frequency.
Urge to urinate is waking up pt and interfering with sleep.
Has to wear pads for protection.
,.oab#
# Restless leg syndrome Intermittent mild symptoms.
Trial of nonpharmacologic options including massage, exercise, stretching and warm bath before bedtime.
Avoid nicotine, alcohol, caffeine.
If symptoms worsen consider gabapentin.
Workup for fatigue, rule out iron deficiency anemia.
114 statnote dot phrases - primary care phrase library
seizures
Seizures Patient has had h/o seizures for years. Compliant with medications.
Last seizure _ ago. Patient has about _ seizures per month.
Patient does follow-up with neurologist. No changes in management during last visit.
seizures#
# Rheumatoid arthritis, hands Mild to moderate ds Treatment options discussed with the patient. DMARDs, steroids, NSAIDs.
,.ra-hands-PE
Multiple joint deformities.
Hand w ulnar deviation and swan neck deformity of multiple fingers.
171 statnote dot phrases - primary care phrase library
,.nce
Rest + ice + NSAlDs + brace.
rotator-cuff
Right shoulder pain Patient complains of gradual onset of anterior and lateral pain. Exacerbated by overhead activities.
Patient cannot sleep unaffected side.
Symptoms have been present for months.
Labor intensive work, carries heavy objects.
Pain relieved w/ NSAIDs.
Denies any injuries or previous surgeries.
No instability symptoms.
No numbness and tingling.
rotator-cuff#
# Right knee osteoarthritis NSAIDs/tylenol prn.
Local analgesia with capsaicin topical. Quadriceps-strengthening exercises.
Knee brace.
Discussed wt loss.
Consider intra-articular corticosteroid injection.
164 statnote dot phrases - primary care phrase library
,.morton-neuroma
Patient complains of pain and numbness of left foot and toes. Interdigital 3/4th digits.
Pain that increases with activity and is usually felt on the plantar surface between the third and fourth toes.
Pt also c/o paraesthesias in the same area at night.
,.morton-neuroma#
# Rosacea Trial of metronidazole topical.
Consider po doxycycline if not improving.
,.rosacea-PE
Erythema of central face, including cheeks, nose, and central forehead. + telangiectasias.
scabies#
# Rotator cuff tendinitis Conservative management. ROM/strengthening exercises.
Consider steroid injection if no improvement.
,.rotator-cuff-PE
Right shoulder No obvious deformities.
Pain with abduction past 90 degrees. + Hawkins.
Neers.
Pain w/ resisted external rotation. Pain w/ empty-can test.
Neg scarf test.
172 statnote dot phrases - primary care phrase library
,.rotator-cuff-inj
Shoulder injection, right Procedure:
After discussion of risks and benefits of corticosteroid injection, including but not limited to infection, bleeding, discomfort with injection, skin atrophy or color changes, injury to surrounding structures, elevated blood sugar, and the possibility of no improvement in pain symptoms patient gave verbal and written consent.
Time-out performed and site of injection was verified and patient identified by name and DOB.
Shoulder was prepped with betadine x 3. Ethyl chloride used for local anesthesia.
4 cc of 1% lidocaine and 40 mg of triamcinolone was mixed and then injected into the glenohumeral joint using a posterior approach with a 22 gauge needle.
Patient tolerated procedure well and was hemostatic at conclusion. Aftercare instructions provided, including returning to clinic if shoulder becomes warm, red, or more painful in the next 72 hours and limiting activity for the next 24-48 hours.
,.rotator-cuff-inj*
20610
shoulder
Right shoulder pain Patient complains of gradual onset of anterior and lateral pain. Exacerbated by overhead activities.
Patient cannot sleep unaffected side.
Symptoms have been present for months Labor intensive work, carries heavy objects.
Pain relieved w/ NSAIDs Denies any injuries or previous surgeries.
No instability symptoms.
173 statnote dot phrases - primary care phrase library
No numbness and tingling.
shoulder-PE-labral
Labral tests + O’Briens, less pain with slap retention test. + Crank.
splint-finger
Static splint applied over volar aspect to immobilize right middle finger. Buddy taped to index finger.
splint-finger-static*
29130
steroid-injection*
20610
strapping-ankle
Right ankle strapping done in office.
strapping-ankle*
29540
174 statnote dot phrases - primary care phrase library
,. s trapping-knee
Right knee strapping done in office.
strapping-knee*
29530
,.thumb-cmc
Patient c/o right thumb pain x months .
Localized to the base of the thumb.
Aggravated by sustained grasping or pinching or by forceful use of the thumb, such as turning a key. Reports a sensation of thumb weakness.
Denies any injuries.
,.thumb-cmc#
# STD Ceftriaxone IM 250 mg xl given.
Rx Azithromycin 1 g xl.
Abstain from sexual activity xl wk.
Notify partners with sexual contact in the last 60 days. Consider Expedited Partner Therapy (EPT).
,.tb-clear
Record of Latent Tuberculosis Treatment Completion
The following is a record of evaluation and treatment for latent tuberculosis infection:
Tuberculin Skin Test (TST):
Date:__ Results (in millimeters of induration):__
1GRA:
99 statnote dot phrases - primary care phrase library
Date:_ Type of test: Gold quantiferon. Result: positive.
Chest radiograph: Date:_ Results: normal.
Date medication started:__. Date completed:__. Medication(s):_
This person is not infectious. Patient may always have a positive TB skin test, so there is no reason to repeat the test. If you need any further information, please contact my office.
,.tb-latent
Latent TB + PPD/gold quant.
Not pregnant, HIV uninfected.
CXR was unremarkable.
No heavy alcohol use.
Pt denies cough, fever, night sweats, weight loss or any other constitutional symptoms.
Not taking warfarin, contraceptives, antiarrhythmics.
vtb-latent#
# Scabies Rx permethrin x2.
Advised tx for all members of household.
Instructed pt on decontamination of linens, clothing, furniture, etc. Short course tx w/ hydrocortisone.
Benadryl prn itching.
Liberal use of emollients.
58 statnote dot phrases - primary care phrase library
,.scabies-PE
Multiple burrows along erythematous papules on elbows, around umbilicus, lower abdomen, upper and lower extremities. Head and neck spared, excoriations 2/2 scratching.
seborrheic-dermatitis
Seborrheic dermatitis C/o itching and scaling on glabella, scalp, nasolabial fold. Reports some redness.
seborrheic-dermatitis#
# Sebaceous cyst I&D/excision. Wound care.
,.sebaceous-cyst-PE
Skin-colored subcutaneous nodule. _ cm. Mobile. Not tender to palpation.
250 statnote dot phrases - primary care phrase library
,.sebaceous-cyst-i&d*
10060
sebaceous-cyst-i&d-proc
Sebaceous cyst l&D/excision Location: right _ Dimensions: _ mm Consent obtained.
Local anesthesia achieved with approx. 1 cc of 1% lidocaine with epinephrine. Area cleaned with 10% betadine solution.
3 mm incision made with sterile #11 blade scalpel. Small amount of white thick material was expressed.
Cyst wall was grasped with forceps and partially excised.
Hemostasis achieved with compression.
Wound dressed with dry, sterile dressing. Pt tolerated well.
,.sebaceous-cyst-proc
Sebaceous cyst excision Location: right _ Size: _ cm Preparation and technique: informed consent was obtained, position prone, sterile preparation of site (in usual fashion, with 10 % povidone iodine, draped to expose affected area, sterile gloves used), local anesthesia 1% lidocaine with epinephrine, 5 cc used.
Elliptical incision was made at center of lesion to include the punctum with 15-blade scalpel. Cyst wall gradually dissected away from the surrounding tissue carefully with Iris scissors and scalpel. Lesion removed in its entirety with scalpel and adson forceps, after cyst wall was freed from the surrounding tissue. While dissecting the lesion, small amount of white thick material was incidentally extruded from the punctum area, confirming diagnosis.
Hemostasis achieved.
251 statnote dot phrases - primary care phrase library
Intermediate repair: layered closure of subcutaneous tissue using 4-0 vicryl, _ sutures placed.
Wound closed with 4-0 nylon suture, _ simple interrupted sutures placed. Triple antibiotic ointment and bandaid applied.
Specimen sent to pathology
surgical-tray*
A4550
,. suture-removal
Here for suture removal.
Wound healing well.
Patient denies any bleeding or discharge. No swelling or redness.
No fevers or chills.
Doing daily wound care.
suture-removal#
Wound healing well. Continue wound care.
,. su ture-removal-PE
Surgical wound clean and dry.
varicose-veins
Varicose-veins C/o leg swelling and fatigue and aching with prolonged standing.
252 statnote dot phrases - primary care phrase library
Reports skin changes.
,.varicose-veins#
# Seborrheic dermatitis Short-term course of topical steroids. Daily use of clotrimazole
,.seborrheic-dermatitis-PE
Loose, greasy scales within erythematous, fine patches involving forehead, nasolabial folds and chin.
,.senile-purpura
Pt c/o bilateral hand bruising. Not on anticoagulant.
No h/o trauma.
,.senile-purpura-PE
Multiple purpuric macule and patches on bilateral dorsal hands and extensor forearms.
59 statnote dot phrases - primary care phrase library
,. senile-purpura#
# Seborrheic keratosis Reassured pt. Monitor.
,.sk-PE
lxl cm “stuck-on” appearance, hyperpigmented lesion w/ wart-like texture located on face.
j.sk-irritated#
# Seborrheic keratosis, irritated Cryotherapy done.
v skin- tag
Pt c/o skin tag located on _ Present for months.
Irritated when caught on jewelry or rubbed by clothing.
skin-tag#
# Seizures Stable. Continue current medications unchanged. Follow-up with Neurology.
Benzodiazepines at home PRN seizures.
,.spinal-cord-inj
Here accompanied by caregiver _.
Para/Quadra plegia d/1 spinal cord injury at _ level after _ years ago.
Pt is wheelchair bound.
Neurogenic bladder. Pt does intermittent self cath q4h. No recent UTIs. Neurogenic bowel. Compliant with bowel regimen.
No reported episodes of autonomic dysreflexia.
No reported skin lesions.
Pt is being followed at _. By Dr.
No changes in management during last visit.
,.spinal-cord-inj#
# Senile purpura Minimize trauma to skin as possible (wear layer of clothing to protect arms).
Sun avoidance/photoprotection.
Reassurance. Self-limited condition.
Avoid aspirin.
Consider topical amlactin solution for dry skin.
,.shave-bx
Shave Biopsy of _Left upper back lesion: size _ Skin cleaned with 70% alcohol swab. Area anesthetized with 1% Lidocaine. Area was prepped in usual sterile fashion with 10% Iodine swab and sterile drapes, and sterile gloves used. Lesion shaved off with Dermablade. Hemostasis achieved with drysol and direct pressure. Triple antibiotic ointment and bandaid applied. Specimen sent to pathology.
,.shave-bx* (not removal of lesion)
11102
,.shave-bx*-trunk/arm/leg <0.5 cm
11300
,.shave-bx*-trunk/arm/leg 0.6-1 cm
11301
60 statnote dot phrases - primary care phrase library
,.shave-bx*-trunk/arm/leg 1.1-2 cm
11302
,.shave-bx*-trunk/arm/leg >2 cm
11303
,.shave-bx*-scalp/neck/hand <0.5 cm
11305
,.shave-bx*-scalp/neck/hand 0.6-1 cm
11306
,.shave-bx*-scalp/neck/hand 1.1-2 cm
11307
,.shave-bx*-scalp/neck/hand >2 cm
11308
,.shave-bx*-face <0.5 cm
11310
61 statnote dot phrases - primary care phrase library
,.shave-bx*-face 0.6-1 cm
11311
,.shave-bx*-face 1.1-2 cm
11312
,.shave-bx*-face >2 cm
11313
,. shingles
Shingles Pt c/o rash on _ Painful and itchy. Present for days.
,. shingles#
# Sialadenitis Recurrent (<3x/yr).
No infection.
Conservative management.
Hydration, pain relief, and sialogogues.
Suck lemon/tart candies. Massage and milk the duct.
Refer to ENT if not improving with conservative management or recurring.
,.sialadenitis-PE
Right cheek: edematous, tender to palpation, no exudates from salivary gland opening.
83 statnote dot phrases - primary care phrase library
red-eye
C/o _ red eye x days Denies decreased vision or foreign body sensation. + mild, burning pain, sandy/gritty feeling in the eye. + URI sx’s.
No periocular tenderness Endorses mild purulent/watery d/c.
Eyelids stuck together in am.
itching, pt has h/o allergies.
No contact lens use.
,.stye
Pt c/o _ upper eyelid lesion present for wks. Some pain and discomfort.
Not affecting vision.
No purulence.
No fever or chills.
,.stye#-Chalazion (Chillnopain)
# Skin tags Lesions removed.
Wound care at home reviewed.
63 statnote dot phrases - primary care phrase library
,.skin-tag-PE
Pedunculated skin colored lesion on
skin-tag-removal
Removal of skin tags - _bilateral neck area:
Skin cleaned with 70% alcohol swab.
_ skin tags excised easily with Iris scissors. Hemostasis achieved with drysol and direct pressure. Triple antibiotic ointment and bandaid applied
skin-tag-removal*
11200
solar-lentigo#
# Snoring, OSA screen STOP BANG score _ High risk of OSA (5-8) Intermediate risk of OSA (3-4)
7 statnote dot phrases - primary care phrase library
Low risk of OSA (0-2) Referred to sleep medicine for sleep study.
overweight
Overweight Diet: high carbs.
Sugary drinks: occasional. Etoh: occasional. Sedentary lifestyle.
overweight#
# Solar lentigo Reassured. Monitor.
Photoprotection.
Consider bx if enlarging or darkening. Consider cryotherapy or laser if bothersome.
solar-lentigo-PE
lxl cm smooth light brown pigmented macule on _
solar-lentigo
Pt c/o dark spot on face.
Similar lesions on dorsal hands and forearms. + sun exposure, no photo-protection use.
64 statnote dot phrases - primary care phrase library
Present for months.
Not increasing in size or changing in color.
tinea-inguinale
Patient complains of skin lesion present on groin, x months.
Worsening.
Itching.
,.tinea-inguinale#
# Sports Physical Cleared for all sports participation without restriction. Vision screen: Un/corrected.
Hgb: WNL.
UA: WNL.
Counseling:.
Diet - balanced diet, avoid junk food.
Accident prevention — bike helmet, risk taking behavior.
Guidance — smoking, alcohol, drugs, peer pressure, regular exercise, academic activities.
Return for next WCC.
,.sports-physical-PE
General: well nourished and developed. No obvious Marfan stigmata. No
abuse/neglect evident.
Head: no lesions.
Eyes: PERRL, conjunctivae, sclera clear.
Ears: Canals clear, TMs normal. No cauliflower ear. Normal hearing. Nose: Passages clear, no lesions.
Teeth: normal dentition.
Neck: Supple, no masses, no thyromegaly. No LAD.
Chest: Symmetrical.
Heart: No murmurs. Regular rhythm.
Lungs: Clear to auscultation.
Abdomen: Soft, no masses, no tenderness, no organomegaly.
Genitalia: Grossly normal, normal development.
Male: Testes down, no lesions or masses. No inguinal hernias. Extremities: No deformities, full range of motion, no edema, pulses strong and equal.
Skin: Clear, no lesions.
Neurologic: alert, physiological. CN 2-12 WNL.
Psych: Appropriate affect with appropriate conversation.
188 statnote dot phrases - primary care phrase library
Musculoskeletal: no scoliosis. Full range of motion. Equal strength and mobility of major joint and muscle groups.
,.wcc-mo-0-l
Here for WCC.
Birth history: born at term, NSVD. Pregnancy complications: none.
Birth weight: _.
Prenatal complications: none.
Interval history: as above Feedings: breast-feeding every 2-3 hours. Stools: after each meal.
Cord: present/fell Circumcision: no.
Infant sleeping position: back.
Exposure to tobacco smoke: no. Growth and development:
Prone, lifts head briefly.
Moro reflex present.
Turns head side to side.
Blinks at bright light.
Responds to sound.
,.wcc-mo-0-l#
Well child exam.
Nutritional assessment made.
Counseling:
Diet - breast vs. formula feeding, burping, no other p.o. intake, no bottle recumbent.
Behavior - feeding, sleeping, crying, hiccoughs, stools, sneezing. Accident prevention — falls, ability to roll, smoke detector, burns from hot liquids.
189 statnote dot phrases - primary care phrase library
Guidance - spoiling, sibling relationships, diaper rash, circumcision care, cord care, suctioning, pacifier, smoking at home, stimulating with hanging objects and bright colors, thermometer use, call MD for fever.
Infant car seat, crib safety reviewed.
f/u for 2 mo WCC.
,.wcc-mo-01-2
Here for WCC.
Interval history: no interim relevant events.
Diet: Breast-feeding.
Illnesses: none.
Stools: after each meal.
Meds/vitamins: none.
Accidents: none.
Sleep pattern: up to 16 to 17 hours a day. two to four hours at a time. Exposure to tobacco smoke: none.
Growth/development:
Prone, lifts head 45deg.
Vocalizes (cooing).
Smiles responsively (social).
Follows past midline.
Kicks.
Grasps.
,.wcc-mo-01-2#
Well child exam.
DTaP#l given. (Pediarix) HepB#2 given. (Pediarix) IPV#1 given. (Pediarix) Rota#l given.
FIiB#l given.
PCV#1 given.
190
) statnote dot phrases - primary care phrase library
Vaccine reactions, risks and follow-up explained.
Nutritional assessment made.
Counseling:
Diet - breast vs. formula feeding, no milk or honey till 1 y/o, no bottle recumbent, feeding position, colic.
Behavior - crying, thumb sucking, no discipline yet.
Accident prevention - rolling, playpen use, burns from hot liquids. Guidance - fever, acetaminophen dose, hot water temp 120deg F, ABCD’s to hear, smoking at home.
Safety precautions - infant car seat, water safety, falls, nursery equipment. Parental smoking discussed.
Childcare plan reviewed.
Emergency care plan reviewed.
Sibling and family relationships discussed.
Thermometer use reviewed.
Umbilical care reviewed.
Infant care (bathing, skin, clothing) reviewed.
f/u for 4 mo WCC
,.wcc-mo-03-4
Here for WCC.
Interval history: no interim relevant events.
Diet: Breast-feeding, formula supplementation.
Illnesses: none.
Stools: no constipation.
Meds/vitamins: none.
Accidents: no.
Sleep pattern: up to 16 to 17 hours a day. two to four hours at a time. Exposure to tobacco smoke: no.
Growth/development:
Head steady when sitting.
Eyes follow 180deg.
Grasps ratde.
Rolls side to side.
191 statnote dot phrases - primary care phrase library
Squeals or goos. Orients to voices.
,.wcc-mo-03-4#
Well child exam.
Rota#2 given.
DTaP#2 given.
Hib#2 given.
PCV#2 given.
IPV#2 given.
Vaccine reacdons, risks and follow-up explained.
Nutritional assessment made.
Counseling:
Diet - breast vs. formula feeding, no milk or honey till 1 y/o, no bottle recumbent, feeding position, colic.
Behavior - rolling, reaching for objects.
Accident prevention - rolling, playpen use, burns from hot liquids. Guidance - teething, no bottle recumbent, URI treatment, aspiration risk with small objects, language stimulation, no discipline yet.
Safety precautions - infant car seat, water safety, falls, nursery equipment, smoke detector, hot water temp, choking prevention.
Childcare plan reviewed.
Emergency care plan reviewed.
Sibling and family relationships discussed.
Thermometer use reviewed.
Minor illness care reviewed.
Umbilical care reviewed.
Infant care (bathing, skin, clothing) reviewed.
Family spacing discussed.
f/u for 6 mo WCC
192 statnote dot phrases - primary care phrase library
,.wcc-mo-05-6
Here for WCC.
Interval history: no interim relevant events.
Diet: Breast-feeding, formula supplementation. Illnesses: none.
Stools: no constipation.
Meds/vitamins: none.
Accidents: no.
Sleep pattern: several naps, more night-time sleep. Exposure to tobacco smoke: no. Growth/development:
No head lag when pulled to sitting.
Reaches for objects.
Bears weight on legs.
Orients to bell.
Rolls both ways.
Sits briefly alone.
Gums, teethes objects.
Babbles.
,.wcc-mo-05-6#
Well child exam.
DTaP#3 given. (Pediarix) HepB#3 given. (Pediarix) IPV#3 given. (Pediarix) Rota#3 given.
HiB#3 given.
PCV#3 given.
Vaccine reactions, risks and follow-up explained.
Nutritional assessment made.
Counseling:
Diet - intro solids at 5 mos (rice cereal, vegs, fruit), solids 1 new/week, start with iron-rich, no milk yet, breastfeeding, formula.
Behavior - begins to sit and crawl, discrimination of people.
193 statnote dot phrases - primary care phrase library
Accident prevention - smoke detector, poisoning risk, drug and toxic chemical storage, poison center phone number, childproofing: safety gates, pool fence, hot liquids and surfaces, hot water temp, choking prevention. Guidance - consistent sleep schedule, teething, blocks, repetitive games, no bottle recumbent, parent smoking.
Infant vs. toddler car seat discussed.
Infant care (bathing, skin, clothing) reviewed.
Childcare plan reviewed.
f/u for 9 mo WCC
,.wcc-mo-07-9
Here for WCC.
Interval history: no interim relevant events. Diet: introduced solids.
Illnesses: none.
Stools: no constipation.
Meds/vitamins: none.
Accidents: no Sleep pattern: few naps, more night-time sleep. Exposure to tobacco smoke: no. Growth/development:
Sits without support.
Feeds self cracker.
Transfer objects hand to hand.
Mama, dada indiscriminately.
Begins to creep and crawl.
Looks for toys dropped.
Teeth.
,.wcc-mo-07-9#
Well child exam.
Hct done. Vaccines UTD.
194 statnote dot phrases - primary care phrase library
Counseling:
Diet — mashed table food, finger foods, start cup.
Behavior - sitting, crawling, creeping, trying to pull self up.
Accident prevention - no food chunks or hard objects the size of a baby’s pinky, smoke detector, poisoning risk, drug and toxic chemical storage, poison center phone no., burns: hot liquids and foods, water / pool safety. Guidance — decrease in appetite, understands “no” but not discipline, brush teeth, no bottle recumbent.
Toddler car seats >201bs.
Teething problems reviewed.
Dental hygiene discussed.
Childcare plan reviewed.
f/u for 12 mo WCC
,.wcc-mo-10-12
Here for WCC.
Interval history: no interim relevant events.
Diet: table food.
Illnesses: none.
Stools: no constipation.
Meds/vitamins: none.
Accidents: no.
Sleep pattern: couple naps, more night-time sleep. Exposure to tobacco smoke: no. Growth/development:
Pulls self to standing.
Stands holding on.
Holds cup to drink.
Dada, mama.
Thumb-finger grasp.
Plays pat-a-cake.
Walks with help.
Scribbles.
195 statnote dot phrases - primary care phrase library
wcc-mo-10-12#
Well child exam.
HepB#3 given. HIB#4 given. PCV#4 given. IPV#4 given. MMR#1 given. Var#l given. HepA#l given.
Labs: sent for CBC and Lead.
Nutritional assessment made.
Counseling:
Diet - intro meats and proteins, mashed table food, finger foods, start feeder cup, milk, junk food, weaning, normal decreased appetite.
Behavior — minor discipline, pulls to standing.
Accident prevention — no hard objects the size of baby’s pinky, smoke detector, drug and toxic chemical storage, poison center phone no., childproofing: electrical outlet covers, safety gates, pool fence, hot liquids and surfaces, hot water temp., drowning, gun in home, falls, walkers, stairs. Guidance - allow to feed self, look in mirror, play with cloth book, expect growth and appetite to decrease.
Toddler car seats.
Childcare plan reviewed.
f/u for 15 mo WCC
,.wcc-mo-13-15
Here for WCC.
Interval history: no interim relevant events. Diet: table food.
Illnesses: none.
Stools: no constipation.
196 statnote dot phrases - primary care phrase library
Meds/vitamins: none.
Accidents: no.
Sleep pattern: couple naps, sleeps most of the night. Exposure to tobacco smoke: no. Growth/development:
Walks alone well.
Takes lid off containers.
Dada, mama, specific.
3 word vocabulary.
Feeds self.
Plays pat-a-cake.
Stoops and recovers.
Scribbles.
2 block tower.
,.wcc-mo-l 3-15#
Well child exam.
HepB#3 given. DTaP#4 given. FI1B#4 given. PCV#4 given. IPV#4 given. MMR#1 given. Var#l given. HepA#l given.
Nutritional assessment made.
Counseling:
Diet - table food, milk, junk food, using cup/botde, encourage solids. Behavior - feeding self, simple games.
Accident prevention - no hard objects the size of baby’s pinky, smoke detector, drug and toxic chemical storage, poison center phone no., childproofing: safety gates, pool fence, hot liquids and surfaces, hot water
197 statnote dot phrases - primary care phrase library
temp., drowning, gun in home, home first aid kit, matches, cabinets and latches.
Guidance — explain temper tantrums, not ready for toilet training, botde, toothbrush.
Toddler car seats.
Childcare plan reviewed.
Emergency care plan reviewed.
f/u for 18 mo WCC
,.wcc-mo-16-23
Here for WCC.
Interval history: no interim relevant events.
Diet: table food.
Illnesses: none.
Stools: no constipation.
Meds/vitamins: none.
Accidents: no.
Sleep pattern: couple naps, sleeps through the night. Exposure to tobacco smoke: no. Growth/development:
Walks alone well.
Takes lid off containers.
Dada, mama, specific.
3 word vocabulary.
Feeds self.
Plays pat-a-cake.
Stoops and recovers.
Scribbles.
2 block tower.
,.wcc-mo-l 6-23#
Well child exam.
198 statnote dot phrases - primary care phrase library
Vaccines are UTD.
Nutritional assessment made.
Counseling:
Diet - regular meals with snacks, cup only: no bottle (12-15mos), junk food.
Behavior — runs but falls easily, loves rough play.
Accident prevention - no hard objects the size of baby’s pinky, smoke detector, drug and toxic chemical storage, poison center phone no., childproofing: safety gates, pool fence, hot liquids and surfaces, hot water hemp., drowning, gun in home, falls from chairs.
Guidance - reading to child, toilet awareness not training, toothbrush use, parent smoking.
Toddler car seats.
Childcare plan reviewed.
Emergency care plan reviewed.
f/u for 2 yr WCC
,.wcc-pe-infant
General: well nourished and developed.
No abuse/neglect evident.
Head: no lesions.
Eyes: PERRL, conjunctivae, sclera clear. + Red reflex bilat. Ears: Canals clear, TMs normal.
Nose: Passages clear, no lesions.
Teeth: grossly normal.
Neck: Supple, no masses, no thyromegaly.
Chest: Symmetrical.
Heart: No organic murmurs, regular rhythm.
Lungs: Clear to auscultation.
Abdomen: Soft, no masses, no tenderness, no organomegaly. Hips: Good abduction, no hip click noted.
Genitalia: Grossly normal, normal development.
Male: Testes down, no lesions.
199 statnote dot phrases - primary care phrase library
Extremities: No deformities, full range of motion. Femoral pulses: normal.
Lymph nodes: not enlarged.
Back: No scoliosis.
Skin: Clear, no significant lesions.
Neurologic: alert, physiological.
,.wcc-pe-pub/ teen
General: well nourished and developed.
No abuse/neglect evident.
Head: no lesions.
Eyes: PERRL, conjunctivae, sclera clear. + Red reflex bilat. Ears: Canals clear, TMs normal.
Nose: Passages clear, no lesions.
Teeth: grossly normal.
Neck: Supple, no masses, no thyromegaly.
Chest: Symmetrical.
Heart: No organic murmurs, regular rhythm.
Lungs: Clear to auscultation.
Abdomen: Soft, no masses, no tenderness, no organomegaly. Genitalia: Grossly normal, normal development.
Male: Testes down, no lesions. Tanner stage:
[Genital
Prepubertal
Normal size testicles
Penis enlargement
Penis increased breadth Pubic Hair
Prepubertal
Fine hair
Curly hair.
Complete fulled triangle
hair spreads to medial aspect of thighs Breast
prepubertal
200 statnote dot phrases - primary care phrase library
BReast lumps/buds
Elevated Areola
Separation of breast
Total breast development]
Extremities: No deformities, full range of motion. Back: No scoliosis.
Skin: Clear, no significant lesions.
Neurologic: alert, physiological.
,.wcc-pe-toddler/child
General: well nourished and developed.
No abuse/neglect evident.
Head: no lesions.
Eyes: PERRL, conjunctivae, sclera clear. + Red reflex bilat. Ears: Canals clear, TMs normal.
Nose: Passages clear, no lesions.
Teeth: grossly normal.
Neck: Supple, no masses, no thyromegaly.
Chest: Symmetrical.
Heart: No organic murmurs, regular rhythm.
Lungs: Clear to auscultation.
Abdomen: Soft, no masses, no tenderness, no organomegaly. Genitalia: Grossly normal, normal development.
Male: Testes down, no lesions.
Extremities: No deformities, full range of motion.
Lymph nodes: not enlarged.
Back: No scoliosis.
Skin: Clear, no significant lesions.
Neurologic: alert, physiologica
,.wcc-pe-toddler/child
General: well nourished and developed.
No abuse/neglect evident.
Head: no lesions.
Eyes: PERRL, conjunctivae, sclera clear. + Red reflex bilat. Ears: Canals clear, TMs normal.
Nose: Passages clear, no lesions.
Teeth: grossly normal.
Neck: Supple, no masses, no thyromegaly.
Chest: Symmetrical.
Heart: No organic murmurs, regular rhythm.
Lungs: Clear to auscultation.
Abdomen: Soft, no masses, no tenderness, no organomegaly. Genitalia: Grossly normal, normal development.
Male: Testes down, no lesions.
Extremities: No deformities, full range of motion.
Lymph nodes: not enlarged.
Back: No scoliosis.
Skin: Clear, no significant lesions.
Neurologic: alert, physiological.
,.wcc-yrs-02
Here for WCC.
Interval history: no relevant interim events. Diet: breakfast: __, lunch: dinner: __, snacks: _.
201 statnote dot phrases - primary care phrase library
Illnesses: none.
Stools: no constipation.
Meds/vitamins: none.
Accidents: no.
Sleep pattern: couple naps, sleeps through the night. Screen time: <2 hours.
Exposure to tobacco smoke: no. Growth/development:
Runs well, walks up and down.
Identified 1 body part.
Kicks and throws a ball.
7-20 word vocabulary.
Puts on simple clothes.
Puts 2-3 words together.
Handles spoon well.
Plays hide and seek.
3 block tower.
Helps in house.
,.wcc-yrs-02#
Well child exam.
Vaccines are UTD.
Hct done.
UA done.
Nutritional assessment made.
Counseling:.
Diet - regular meals with snacks, iron-rich foods, sodium, caloric balance, switch to lowfat milk. Tap water.
Behavior — Disciple, tantrums, time out, imitates .
Accident prevention - street dangers, falls, drowning, poison center, storage of drugs, toxic chemicals, guns, smoke detectors, hot water temp, pool fence, bike helmet.
202 statnote dot phrases - primary care phrase library
Guidance - start toilet training, parallel peer play, monitor TV programs, brush teeth, dentist ql -2 years, effects of passive smoking, protect skin from UV light.
Toddler car seat.
Childcare plan reviewed.
Emergency care plan reviewed.
f/u for 3 yr WCC
,.wcc-yrs-03
Here for WCC.
Interval history: no relevant interim events. Diet: breakfast: __, lunch: __, dinner: __, snacks: __. Illnesses: none.
Stools: no constipation.
Meds/vitamins: none.
Accidents: no.
Sleep pattern: naps, 10 hrs at night.
Screen time: <2 hours.
Exposure to tobacco smoke: no. Growth/development:
Goes up stairs alternating feet.
Plays with other children.
Knows age, sex, first and last name.
Balance on each foot, 1 second.
Vocabulary of about 500 words.
Helps in dressing.
Copies +.
20 teeth.
Cuts with scissors.
,.wcc-yrs-03#
Well child exam.
203 statnote dot phrases - primary care phrase library
Vaccines are UTD.
Hct done.
Vision screening. Audiometry.
Nutritional assessment made. Dental referral.
Counseling:
Diet - regular meals with snacks, caloric balance, sweets, iron. Tap water. Behavior — model appropriate language, praise good behavior, encourage self-expression of feelings (anger/sadness/frustration), very aware of peers. Accident prevention - street dangers, knives, falls, drowning, caution with strangers, smoke detectors, hot water temp, pool fence, play equipment, bike helmet, poison center phone, storage of drugs, toxic chemicals, guns. Guidance - read together, TV programs, regular exercise, brush teeth, dentist ql-2 years, UV skin protection, parent smoking.
Toddler car seat till 4 years and under 40 lbs.
Childcare plan reviewed.
Emergency care plan reviewed.
f/u for 4 yr WCC
,.wcc-yrs-04-5
Here for WCC.
Interval history: no relevant interim events. Diet: breakfast: __, lunch: __, dinner: __, snacks: __. Illnesses: none.
Stools: no constipation.
Meds/vitamins: none.
Accidents: no.
Sleep pattern: naps, 10 hrs at night.
Screen time: <2 hours.
Exposure to tobacco smoke: no. Growth/development:
204 statnote dot phrases - primary care phrase library
Hops on one foot.
Counts 4 pennies.
Copies a square.
Catches, throws a ball.
Plays with several children. Recognizes 3-4 colors.
Knows opposites.
Knows name, address, phone number.
,.wcc-yrs-04-5#
Well child exam.
DTaP given. IPV given. MMR given. VAR given.
Hct done.
UA done.
Vision screening. Audiometry.
Nutritional assessment made. Dental referral.
Counseling:
Diet - regular meals with snacks, caloric balance, sweets, iron. Tap water. Behavior — model appropriate language, praise good behavior, encourage self-expression of feelings (anger/sadness/frustration), very aware of peers. Accident prevention - street dangers, falls, drowning, caution with strangers, smoke detectors, hot water temp, window guards, pool fence, play equipment, bike helmet, poison center phone, storage of drugs, toxic chemicals, matches, guns.
Guidance — knows name, address and phone no., plays with other children, imitates adults, dressing self, brushing own teeth, school plans, TV
205 statnote dot phrases - primary care phrase library
programs, regular exercise, UV skin protection, dentist ql-2 yrs, parent smoking.
Seat belt use.
Childcare plan reviewed.
Emergency care plan reviewed.
f/u for 5/6 yr WCC
,.wcc-yrs-06-8
Here for WCC.
Interval history: no relevant interim events.
Diet: breakfast: __, lunch: __, dinner: __, snacks: __.
Illnesses: none.
Weight loss/gain: not significant.
Stools: no constipation.
Illnesses, stomach, headache, fatigue: no.
Fatigue, nightmares, enuresis: no.
Meds/vitamins: none.
Accidents: no.
Sleep pattern: naps, 10 hrs at night.
Screen time: <2 hours.
Exposure to tobacco smoke: no.
Growth/school progress (achievement, sports, peer relationships, attendance, school vision or hearing problems): no.
Balances on 1 foot.
Dances, swims, rides a bicycle.
Knows left from right.
Like table/ board games.
Prints numbers to 10.
Other- prints first name, draws person with 6 parts.
,.wcc-yrs-06-8#
Well child exam.
206 statnote dot phrases - primary care phrase library
DTaP given. IPV given. MMR given. VAR given.
Hct done.
UA done.
Vision screening. Audiometry.
Nutritional assessment made. Dental referral.
Counseling:
Diet - limit sweets, sodium, fat (esp sat + chol), snacks, balanced meals. Accident prevention - bike helmet, water safety, car safety, smoke detector, storage of guns, drugs, toxic chemicals, matches.
Guidance - bed time, discipline, tooth brushing, dentist ql-2 years, UV skin protection, regular exercise, school achievement, fun, friends, family life education, child sexual abuse.
Seat belt use.
f/u for next WCC or pm.
,.wcc-yrs-09-12
Here for WCC.
Interval history: no relevant interim events. Diet: breakfast: __, lunch: __, dinner: __, snacks: __. Appetite: good.
Physical activity: frequent.
Weight loss /gain: no.
Stools: no constipation.
Illnesses, stomach, headache, fatigue: no. Meds/vitamins: none.
Accidents: no.
Sleep pattern: naps, 10 hrs at night.
207
\ statnote dot phrases - primary care phrase library
Screen rime: <2 hours. Exposure to tobacco smoke: no.
HEADSS Lives @ home. Safe environment.
Attends _th grade. Doing ok at school. Grades: (A/B). Not currently employed.
Activities: Plays _.
Denies using tobacco/alcohol/drugs. No pressure from peers.
Not sexually active.
Denies any depression symptoms. Not suicidal.
,.wcc-yrs-09-12#
Well child exam.
Hct done.
UA done.
Nutritional assessment made. Dental referral.
Vision screening. Audiometry.
MMR#2 given. Td given.
Varicella given. HepB vax given. Gardasil vax given.
Additional labs:.
Counseling:.
Diet - limit sweets, sodium, fat (esp sat + chol), snacks, balanced meals. Tap water.
Accident prevention - bike helmet, water safety, car safety, smoke detector, storage of guns, drugs, toxic chemicals.
208 statnote dot phrases - primary care phrase library
Guidance — bed time, discipline, smoking, alcohol, marijuana, cocaine, IV and other drugs, family life education, early sex education and puberty progress, exercise 3 times a week, health decisions, TV, school, fun, friends, UV light protection, tooth brushing, dentist yearly, sexual abuse, violence prevention.
Seat belt use.
f/u for next WCC or prn
,.wcc-yrs-13-16
Here for WCC.
Interval history: no relevant interim events. Diet: breakfast: lunch: __, dinner: __, snacks: _. Appetite: good.
Physical activity: frequent.
Weight loss/gain: no.
Stools: no constipation.
Illnesses, stomach, headache, fatigue: no. Meds/vitamins: none.
Accidents: no.
Sleep pattern: naps, 10 hrs at night.
Screen time: <2 hours.
Exposure to tobacco smoke: no.
HEADSS Lives @ home. Safe environment.
Attends _th grade. Doing ok at school. Grades: (A/B). Not currently employed.
Activities: Plays _.
Denies using tobacco/alcohol/drugs. No pressure from peers.
Not sexually active.
Denies any depression symptoms. Not suicidal.
209
: statnote dot phrases - primary care phrase library
,.wcc-yrs-13-16#
Well child exam.
Hct done.
UA done.
Nutritional assessment made.
Dental referral.
Vision screening.
Audiometry.
GC/Chlamydia: done. Not sexually active. Refused.
MMR#2 given. Td given.
Varicella given. HepB vax given. Gardasil vax given.
Additional labs:.
Counseling:.
Diet - healthy diet, caloric balance, appropriate weight, junk food, eating disorders. Tap water.
Accident prevention - bike helmet, risk taking behavior, DUI, guns, violent behavior, motor vehicle safety, work safety.
Guidance - smoking, alcohol, marijuana, cocaine, IV and other drugs, depression, suicidal ideation, puberty progress, sex education (partner selection, condoms, contraception, AIDS risk factors), goals in life, family interaction.
Seat belt use.
Personal development: physical, growth, sexuality, independence.
f/u for next WCC or prn
,.wcc-yrs-17-18
Here for WCC.
Interval history: no relevant interim events.
210 statnote dot phrases - primary care phrase library
Diet: breakfast: lunch:
Appetite: good.
Physical activity: frequent.
Weight loss/gain: no.
Stools: no constipation.
dinner:
snacks:
Illnesses, stomach, headache, fatigue: no. Meds/vitamins: none.
Accidents: no.
Sleep pattern: naps, 10 hrs at night. Screen time: <2 hours.
Exposure to tobacco smoke: no.
HEADSS Lives @ home. Safe environment.
Attends _th grade. Doing ok at school. Grades: (A/B). Not currently employed.
Activities: Plays Denies using tobacco/alcohol/drugs. No pressure from peers.
Not sexually active.
Denies any depression symptoms. Not suicidal.
,.wcc-yrs-17-18#
Well child exam.
Hct done.
UA done.
Nutritional assessment made.
Dental referral.
Vision screening.
Audiometry.
GC/Chlamydia: done. Not sexually active. Refused.
MMR#2 given. Td given. Varicella given. HepB vax given.
211 statnote dot phrases - primary care phrase library
Gardasil vax given.
Additional labs: none.
Counseling:.
Diet - obesity, eating disorders, junk food. Tap water.
Accident prevention - bike helmet, risk taking behavior, DUI, guns, violent behavior, motor vehicle safety, work safety.
Guidance - smoking, alcohol, marijuana, cocaine, IV and other drugs, depression, suicidal ideation, puberty progress, sex education (partner selection, condoms, contraception, AIDS risk factors), goals in life, regular exercise.
Seat belt use reviewed.
Personal development, independence discussed.
Academic, work activities reviewed.
Family, social interaction, communication discussed.
f/u for next WCC or prn
,.wt+bili-check
Here for wt and bili check.
Born at term via repeat LTCS, no complications. Birth wt: _3409 g.
Breast and bottle feeding.
Normal stool and voiding pattern.
No interim events.
,.wt+bili-check#
# Stress incontinence Behavioral approaches + lifestyle changes.
Kegel exercises.
Caffeine reduction, fluid management/reduction.
,.vasectomy*
55250
,.vasectomy-eval
Pt desires not to father any more children. Has 3 kids.
Interested in male sterilization.
Denies any h/o GU surgeries/scars or trauma. Denies any chronic medical conditions.
236 statnote dot phrases - primary care phrase library
,.vasectomy-eval#
# Subconjunctival hemorrhage Reassurance.
Expect resolution in a couple of weeks.
,.subconjunctival-hemorrhage-PE
Left eye: extravasated blood on conjunctiva.
85 statnote dot phrases - primary care phrase library
thrush
Pt c/o white painful lesion on oral mucosa/tongue. Tried to scrape but pain persists.
thrush#
# Sudden hearing loss Referral to ENT.
,.hearing-loss-PE
Bilateral ear exam Normal auricle.
No mastoid tenderness.
Normal ear canal and tympanic membrane.
Normal drum mobility using pneumatic otoscopy. Negative whisper test (repeats 6/6 words).
Weber - symmetric (forehead).
lateralizes to _ (blocked ear in CHL, better ear in SNHL. Rinne - normal (air > bone conduction) (mastoid), negative (bone > air conduction) (CHL).
mucocele
Mucocele Pt c/o painless cyst on lower lip. Present for weeks. Increasing in size. No h/o mouth trauma.
79 statnote dot phrases - primary care phrase library
,.mucocele#
# Sudden hearing loss Referral to ENT.
, .hearing-lo s s -PE
Bilateral ear exam Normal auricle.
No mastoid tenderness.
Normal ear canal and tympanic membrane.
Normal drum mobility using pneumatic otoscopy. Negative whisper test (repeats 6/6 words).
Weber - symmetric (forehead).
lateralizes to _ (blocked ear in CHL, better ear in SNHL. Rinne - normal (air > bone conduction) (mastoid), negative (bone > air conduction) (CHL).
mucocele
Mucocele Pt c/o painless cyst on lower lip. Present for weeks. Increasing in size. No h/o mouth trauma.
79 statnote dot phrases - primary care phrase library
mucocele#
# Syncope Unexplained etiology, possibly vasovagal.
Reflex/neurocardiogenic syncope 2/2.
Single episode, no red flags. - Reassurance.
No suspicion for cardiac etiology, normal EKG, no hx of cardiac ds. no Need for echocardiogram at this point.
No suspicion for neurologic etiology, including seizures or CVA. no Head trauma, no need for CT head at this point.
No need for driving restrictions.
Recommended adequate hydration to avoid orthostatic hypotension. Will check CBC and BMP to eval for anemia or any electrolyte abnormalities.
F/u in 3 months or return to clinic or ED if symptoms recur.
,.syncope-PE
General: NAD.
116 statnote dot phrases - primary care phrase library
Orthostatic VS _normal.
HEENT: NC/AT, no evidence of tongue bites/injury. MMM.
Cardiac: Normal SI and S2, no murmurs, RRR. No carotid bruits. No JVD. Carotid massage: negative (no asystole or dec SBP >50 mmHg). Pulmonary: CTAB.
Neurologic: no focal deficits.
tremor
Pt c/o hand tremors.
Brought out by arm movement/sustained positions.
Affecting daily activities like writing, drinking from a glass and handling eating utensils.
No head or voice involvement.
Symptoms improve with etoh consumption.
Worsens with anxiety.
,.tremor#rest/int
# TB screening Patient is at low-risk for developing tuberculosis.
She would not benefit from TB treatment, therefore further testing is not indicated.
However patient desires to volunteer at school and PPD testing is mandatory.
PPD given.
Return in 48 hours for reading.
101 statnote dot phrases - primary care phrase library
9 NEUROLOGY
,.alzheimer
Alzheimers dementia + memory loss and disorientations. Difficulty naming objects/people. Misplacement of items.
Getting lost.
Apathy.
Decline in activities of daily living. Reports:
Anxiety Insomnia
,.alzheimer#
# TMJ syndrome Joint rest - no gum, excessive talking, soft diet. Reduce stress, physical therapy.
CBT/stress management.
Pain control with NSAIDs and muscle relaxants. Consider referral to maxillofacial sx if persisting.
toenail-debridement
Dremel tool with sanding disc was used to debride bilateral big toenails. Patient tolerated procedure well.
toenail-debridement-1-5*
11720
177 statnote dot phrases - primary care phrase library
,.toenail-debridement-6*
11721
toenail-trimming*
11719
,.toenail-trimming-proc
10 non-dystrophic toenails were trimmed using nail cutter.
triamcinolone*
J3301
trigger-finger
Patient complains of right 4th digit getting stuck.
Painful snapping, catching and locking during flexion.
Difficulty spontaneous extending affected digit, requiring manipulation. Pain localized over volar aspect.
Worse in the morning.
trigger-finger#
# Tinea inguinale Topical antifungal therapy. Cream and powder. Continue for a week after clearing.
Discussed perspiration management.
,.tinea-inguinale-PE
Annular, red/hyperpigmented, scaly plaques extending from the inguinal creases, down to medial thigh, and buttocks. Demarcated edges.
,.tinea-pedis
Patient complains of skin lesion present on feet, x months.
Worsening.
Itching.
,.tinea-pedis#
# Tinea pedis
65 statnote dot phrases - primary care phrase library
Topical antifungal therapy. Cream and powder. Continue for a week after clearing.
Discussed perspiration management.
,.tinea-pedis-PE
Bilateral plantar feet w/ white scaly skin in a “moccasin” distribution.
tinea-versicolor
Patient complains of skin lesion present on torso, x months.
Worsening.
Itching.
tinea-versicolor#
# Tinea versicolor Po fluconazole 1 x/wk x2wk. Perspire during tx days. Topical antifungal therapy.
Continue for a couple of weeks after clearing.
tinea-versicolor-PE
Multiple hypopigmented macules and patches with fine bran-like scale. Lesions are oval and coalesce. Affect in chest and back. No facial involvement.
,.unna-boot*
29580
66 statnote dot phrases - primary care phrase library
,.unna-boot-proc
Procedure: Unna boot.
Location: Right lower extremity.
A 3-inch gauze impregnated with calamine-gelatin-zinc oxide compound was used to place a unna boot compression bandage in a crisscross pattern beginning at the metatarsal-phalangeal joint and ending just below the level of the tibial tuberosity. A second layer was applied using an elastic bandage using the same pattern.
Patient tolerated procedure well. Instructed patient to keep dressing dry and to remove if there are any symptoms of impaired circulation including any paresthesia, discoloration, or worsening discomfort.
,.vitiligo
Pt c/o periorificial depigmentation.
Areas involved include: periocular, perioral, perianal/genital, and axillae. Present for years.
Not improving.
Failed OTC tx.
,.vitiligo#
# Tinnitus Troublesome.
Not affecting quality of life. Education and counseling. Consider CBT.
86 statnote dot phrases - primary care phrase library
6 GASTROENTEROLOGY
asplenia#
# Tobacco use Counseled on smoking cessation for 3 minutes. Readiness to quit: not interested.
Discussed treatment options with nicotine replacement. Discussed available resources like 1-800-NO-BUTTS.
tobacco*
99406
,.transition-of-care
I have reviewed the discharge summary and other pertinent hospital records.
The patient does not have any pending diagnostic tests or treatments.
9 statnote dot phrases - primary care phrase library
No problems or coordination of care issues have been identified today. Medication reconciliation has been completed during today’s visit.
,.transitional-carel 4*
99495
vtransitional-care7*
99496
traveler-advice
Traveling to _ Duration: _ Not visiting relatives/friends. Not staying with locals.
No chronic conditions.
traveler-advice#
# Traveler advice Discussed preventive measures. Vaccines given.
Rx malaria ppx.
10 statnote dot phrases - primary care phrase library
1.1 BILLING CODES
office visit new
office visit established
lowm od
high
<1
1-4
5-11
12-17
18-39
40-64
65+
medicare
transitional care
99202
99203
99204
99213
99214
99215
prev tiled, initial (physical)
prev med, established (physical)
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
annual wellness, initial
annual wellness, subsequent
G0438
G0439
14d/MC
7d/HC
99495
99496
11 statnote dot phrases - primary care phrase library
30
counsel
30+
ACP
tobacco
etoh/substance
prev m ed
99497
99406
99408
99411
99498
psychotherapy
90833
postop t'/u visit
99024
MC: moderate complexity HC: high complexity
,.em+well
Outside of the Annual Wellness/Preventive Medicine E&M Visit, 10 minutes were spent face-to-face with the patient, over 50% of which was spent in counseling regarding die above problems.
,.em-o ffice- n ew-1 c)w
99202
,. em-o ffice-n ew- m od
99203
,. e m-o ffi ce-n ew-high
99204
12 statnote dot phrases - primary care phrase library
,.em-office-cstab-low
99213
,.em-office-estab-mod
99214
,.em-office-es tab-high
99215
em-physical-in i- 1
99381
vem-physical-ini-1 -4
99382
,.em-physical-ini-5-l 1
99383
\
,.em-phy sical-ini-12-17
I
99384
,.em-physical-ini-l 8-39
99385
13 statnote dot phrases - primary care phrase library
,.em-physical-ini-40-64
99386
,.em-physical~ini-65+
99387
,.em -physical-estab-l
99391
,.em -physical-estab-1 -4
99392
,.em -physical-estab-5-l1
99393
,.em -physical-estab-l2-17
99394
,.em -physical-estab-l8-39
\i
99395
\
,.em -physical-estab-40-64
99396
!
14 statnote dot phrases - primary care phrase library
I
,.em-physical-estab-65+
99397
!
,.em-wellness-ini
■j !.
G0438
i
j.em-wellness-subs
G0439
!
I(
transitional-1 4/MC
99495
i
vem-transitional-7 / HC
99496
l
\
15
[
!
I statnote dot phrases - primary care phrase library
1.2 HEALTH MAINTENANCE/PHYSICALS
1
For Well Child Checks see Pediatrics section.
\
This section includes wellness Medicare visits and “physicals. ”The templates, with the prefix “physical”are categorized bj age and gender. I use this template in the HPI section of the office visit note while I use the template "health-maintenance ”in the A/P section.
Health Maintenance These templates are based on current U.S. Preventive Services Task Force guidelines as well as the Centers for Disease Control and Prevention guidelinesfor vaccines. The templates are organized by age, gender and risk factors.
,.health-maintenance~F 18+
# Trigger-finger Conservative management. Corticosteroid injection recommended.
178 statnote dot phrases - primary care phrase library
,.trigger-finger-PE
Palpable nodule in the line of the flexor digitorum superficialis, just distal to the MCP joint in the palm.
,.trigger-finger-inj
Trigger finger injection location: _Right thumb Tender nodule was identified in the finger’s flexor tendon. Entry point was marked 1 cm distal to the nodule. Area was then prepped in the usual sterile fashion. Using a 25 gauge 5/8 inch needle, 0.5 mL of lidocaine and triamcinolone - 20 mg was injected around the nodule into the tendon sheet without difficulty. After injection, the patient was able to move finger through its full range of motion without pain. A sterile dressing was applied. The patient tolerated the procedure well. Aftercare discussed.
trigger-finger-inj *
20550
,.tngger-point-inj
Trigger point injection, _upper back Discussed treatment options, risks, benefits and alternatives. Patient opted for trigger point injection. Patient signed informed consent.
Trigger point injection was given by injecting 2 cc of 0.25% marcaine on each site as below.
Patient experienced immediate relief of symptoms, >50% reduction. Procedure was well tolerated.
Aftercare and return precautions discussed with patient.
Injection sites:
trapezius, left _ / right _ splenius capitis, left _ / right _ rhomboid major, left _ / right _
179 statnote dot phrases - primary care phrase library
latissimus dorsi, left _ / right _ gluteus maximus, left _ / right _ gluteus medius, left _ / right _
trigger-point-inj -steroid
Trigger point injection, _upper back Discussed treatment options, risks, benefits and alternatives. Patient opted for trigger point injection. Patient signed informed consent.
Trigger point injection was given by injecting 2 cc of 4 mg/mL of triamcinolone mix with 0.25% marcaine on each site as below.
Patient experienced immediate relief of symptoms, >50% reduction. Procedure was well tolerated.
Aftercare and return precautions discussed with patient.
Injection sites:
trapezius, left _ / right _ splenius capitis, left _ / right _ rhomboid major, left _ / right _ latissimus dorsi, left _ / right _ gluteus maximus, left _ / right _ gluteus medius, left _ / right _
trigger-point-inj (1)*
20552
trigger-point-inj (3)*
20553
trochanteric-bursitis
Pt c/o pain involving the lateral aspect of the _right hip x weeks. Worsens while standing up.
180 statnote dot phrases - primary care phrase library
trochanteric-bursitis#
# Trochanteric bursitis, _right hip Steroid injection given. Conservative management.
trochanteric-bur sitis-PE
_Right hip: tenderness to palpation at site of bursa. Full ROM. No erythema or edema.
,.trochanteric-bursitis-inj
Trochanteric bursitis injection, right Informed consent was obtained from the patient. With the patient lying on the examination table in the lateral decubitus position on the unaffected hip. The point of maximal tenderness on the greater trochanter was identified and marked and then prepped in the usual sterile fashion. Using a 25 gauge 1.5 inch needle, 3 mL of lidocaine and 40 mg of triamcinolone were injected into the trochanteric bursa without difficulty. After injection, the hip was passively moved through the full range of motion and a sterile dressing was applied. The patient tolerated the procedure well. Aftercare discussed.
,.trochanteric-bursitis-inj*
20610
181 statnote dot phrases - primary care phrase library
,.ulnar-tunnel-sd
Pt complains of mild transient paresthesias mainly in the ring and small fingers.
C/o pain in the medial side of the elbow that radiates to the hand. Denies any weakness, dropping object.
No h/o trauma or previous injury.
ulnar-tunnel-s d
# Ulcerative colitis Stable. No recent flares. Continue current management. Monitor CBC/CMP, vit B12 def. Not on chronic corticosteroids. Colonoscopy up-to-date.
Avoid NSAIDs.
Recommended high-fiber diet.
t
91 statnote dot phrases - primary care phrase library
7 HEMATOLOGY/ONCOLOGY
anemia
Anemia Pt c/o fatigue.
No SOB, CP, palpitations.
No melena or blood in the stool.
,.anemia#Fe
# Ulnar tunnel syndrome, right Conservative management.
NSAIDs.
Elbow brace.
Consider referral to ortho if no improvement.
,.ulnar-tunnel-sd#
# Ulnar tunnel syndrome, right Conservative management.
NSAIDs.
Elbow brace.
Consider referral to ortho if no improvement.
,.ulnar-tunnel-sd-PE
Normal elbow ROM.
Tinnel sign.
elbow flexion test.
No masses or lesions on cubital tunnel region. Normal overall muscle strength.
NVI.
Negative spurling’s test.
182 statnote dot phrases - primary care phrase library
,.wrist-PE
No obvious deformity. No edema. Full passive ROM of wrist on extension and flexion. Diffuse tenderness to palpation over wrist, no specific point tenderness on anatomic snuffbox. Normal sensation and motor strength.
, .wrist-inj
Right wrist injection Area of maximal tenderness on dorsal aspect was marked and then prepped in the usual sterile fashion. Using a 25 gauge 1.5 inch needle, aspiration was attempted but no fluid was withdrawn. 0.5 mL of lidocaine and triamcinolone - 20 mg was injected without difficulty. After injection, the patient was able to move the wrist through the full range of motion and a sterile dressing was applied. The patient tolerated the procedure well. Aftercare discussed.
wrist-inj*
20605
183 statnote dot phrases - primary care phrase library
12 PEDIATRICS
circumcision
Here w/ mother for circumcision. Born at term.
No perinatal complications. Normal voiding patterns.
circumcision#
# Upper back pain W/o radiculopathy.
No red flags.
Tylenol or NSAIDS as first line tx. Rx topicals: capsaicin, lidocaine.
140 statnote dot phrases - primary care phrase library
Consider physical therapy. Printed back exercises handout.
,.back-pain-PE
Rising from chair: normal.
Ambuladon: normal.
Flexibility of spine: normal.
Toe/heel walk: normal.
No midline spine tenderness.
Tender to palpation on _right paraspinal area. ROM: full extension of the leg at the knee. Full dorsiflexion of the great toe.
Full plantar flexion of toe and foot. Sensation on lower extremities: normal. Strength on lower extremities: 5/5.
Pedal pulses: present.
DTR. patellar 2+, ankle reflex 2+.
Negative straight leg raise test.
,.bicep-tendinitis
Pt c/o anterior shoulder pain, right. Exacerbated by lifting or pulling. No h/o injury.
bicep-tendinitis#
# Vaginal atrophy Trial of vaginal moisturizers and lubricants. (Replents, KY-Jelly).
Avoid long term use of Premarin.
,.vaginitis
C/o vaginal discharge for the past days. Endorses vaginal odor.
Denies vaginal itching/burning/irritation. Denies dysuria, frequency, urgency or hematuria. Denies abdominal/pelvic pain.
No recent use of abx.
OTC tx: none.
Sexually active, no new partners.
LMP: wks ago.
,.vaginitis#BV
# Vaginitis Likely Bacterial Vaginosis. Nitrazine pH >4.5, wet mount: clue cells, thin, white d/c. +whiff test.
Tx w/ metronidazole 500 PO bid x 7 days, avoid alcohol during tx.
134 statnote dot phrases - primary care phrase library
Return if symptoms not improving.
,.vaginitis#candida
# Vaginitis Likely Candida Vaginitis. Nitrazine pH <4.5, KOH: pseudohyphae. white, cottage-cheese-like d/c.
Tx w/ Clotrimazole 2% vag crm x3 days/ Fluconazole 150 mg PO xl. Return if symptoms not improving.
,.vaginitis#trichomona
# Vaginitis Likely Trichomoniasis. Nitrazine pH >7. micro: trichomonads. copious malodorous, yellow-green d/c w/ vulvar irritation, strawberry cervix, fishy odor.
Tx w/ metronidazole 2g PO xl. avoid alcohol during tx. rx tx for sex partner, no intercourse until partner tx.
Return if symptoms not improving.
,.vaginitis-PE
General: NAD.
Abdomen: soft, non tender.
Vagina: Healthy pink mucosa, _ discharge, no lesions.
Cervix: No lesions, no cervical motion tenderness, _ discharge. Ext genitalia: Normal, no lesions.
Inguinal lymph nodes not enlarged.
135 statnote dot phrases - primary care phrase library
11 MUSCULOSKELETAL (ORTHO/SPORTS/PODIATRY)
,.ac-joint-inj*
20600
,.ac-joint-in)
AC joint injection, Right AC joint was marked and then prepped in the usual sterile fashion. Using a 25 gauge 1.5 inch needle, 1 mL of lidocaine and triamcinolone - 10 mg was injected into the joint space without difficulty. After injection, the joint was passively moved through the full range of motion and a sterile dressing was applied. The patient tolerated the procedure well. Aftercare discussed.
,.achilles-tendinitis
Pt c/o a sensation of fullness/nodule in the back of the leg/posterior ankle.
C/o localized pain during and following activity.
136 statnote dot phrases - primary care phrase library
,.achilles-tendinitis#
# Varicose veins Sent for LE US.
Compression stockings.
Referred to vascular surgery for evaluation and possible phlebectomy.
,.varicose-veins-PE
Lower extremities dilated tortuous veins.
wound-debridement-1 st20sqcm
11042
,.wound-debridement-subsq
11045
253 statnote dot phrases - primary care phrase library
# Vasectomy evaluation Procedure and pre/post surgical care discussed with patient. Discussed this is a permanent procedure, pt expressed understanding. Consent for sterilization signed.
,.vasectomy-proc
PRE-OP DIAGNOSIS: Desires Elective Sterilization. POST-OP DIAGNOSIS: Same.
PROCEDURE: Elective Bilateral Vasectomy. ANESTHESIA: 1:1 mix Lidocaine 1% with and without epi. Total amount used: 8 mL.
INDICATIONS:
This gendeman desires elective sterilization. He was counseled regarding the risks, alternatives, and benefits of male sterilization by vasectomy. He was informed of the risks of the procedure, including but not limited to failure of the procedure to produce sterility, the risks of bleeding, infection, and injury to scrotal contents. All questions were answered and the required State of California consent form was signed. No guarantees were given or implied. A time out was taken prior to the procedure.
PROCEDURE:
The patient was laid supine on the procedure table. He was sterilely prepped and draped in the usual fashion. The vasa were identified bilaterally. The left vas was grasped using the three-finger technique. Local anesthesia with a 27 gauge needle was applied to the skin in the midline / lateral scrotum and to the left vas and surrounding tissue. A vas fixing forceps was used to grasp the vas through the scrotal skin. A vas dissecting instrument was then used to pierce the skin and down through the fascia. The vas was then identified and delivered through the incision. The surrounding vassal tissue was incised in the midline in a vertical fashion to reveal the vas. The vas was grasped with a vas forceps and delivered out of the fascia. The vas was distally and proximally grasped.
237 statnote dot phrases - primary care phrase library
The intervening segment of approximately 2 cm was excised and sent for pathologic review. The lumen of the vas were sealed with thermal fine wire cautery. The proximal vas was then closed over with fascia in a fascial interposition technique.
Small surgical clips were placed on the distal and proximal ends of the vas and.
The right vas was attended to in the same fashion as the left vas after local anesthesia was applied to the vas and surrounding tissue. All bleeding was controlled. The scrotal fascia was allowed to close by primary intention . Sterile dressings were applied and the patient was sent home with standard post-vasectomy instructions, including instructions to take semen sample to the lab for analysis after 15-20 ejaculations.
238 statnote dot phrases - primary care phrase library
16 SURGERY
abscess
C/o abscess on Present for days.
Became red and painful, worsening. No spontaneous drainage.
No fever or chills.
No h/o trauma or injury.
abscess#
# Vitiligo Widespread, affecting >3% body surface area. Discussed treatment options including:
phototherapy.
topical clobetasol or tacrolimus.
,.vitiligo-PE
Depigmented patches on axillae, perioral, periorbital.
67 statnote dot phrases - primary care phrase library
,.wart
Pt c/o lesion growth over the last few months. Location: _ Painful.
,.wart#
# Wart Cryotherapy done. Salicylic acid gel.
,.wart-PE
Hyperkeratotic, skin colored papule on _
,.wart-plantar#
# Well Woman Check Pelvic exam was unremarkable.
Pap smear done.
Sent specimen for GC and chlamydia.
Breast exam within normal limits.
No family history of breast cancer. Menstrual cycle is regular. No concerns with sexual life or intimate partner violence. Contraception: not interested.
Pt is up-to-date w/ all her immunizations.
Preventive counseling: Diet and exercise reviewed.
,.wwc-hpi
Well woman exam Pt has never had any abnormal pap smears. Her last pap smear was > 3 yrs ago.
Pt is sexually active w/ only one partner. Contraception used: none.
27 statnote dot phrases - primary care phrase library
Not interested in GC/Chlam testing.
Denies any intimate partner violence.
Pt denies any abnormal vaginal bleeding or any vaginal d/c.
Pt is regular and denies any metromenorrhagia.
Denies any breast masses or abnormalities on self-breast exam.
28 statnote dot phrases - primary care phrase library
1.3 PHYSICAL EXAM
These templates (abdomen, ent, cardiopulm) are categorized based on the organ system pertinent to the visit When I listen to the patient’s heart and lungs, 1 use the cardiopulm template. The main template I use is “no-touch" (everything documented can be gathered from entering the room, saying hi to the patient and shaking his or her hand.) This template covers nine organ systems or elements required to be documented for billing purposes. I often start with the “no-touch ”template and then add elements of the physical exam pertinent to the visit. You will see multiple templates in other sections with the suffix -PE (i.e. ,.acne-PE, ,.knee-PE).
,.pe-adult-xshort-(no-touch)
General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
ENT: Hearing grossly intact. No nasal discharge.
Neck: Neck is supple. No masses or thyromegaly.
Respiratory: Respirations are non-labored. No wheezing.
Skin: Warm. No rashes or ulcers.
Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment.
CV: No lower extremity edema.
MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Sensation and CN II-XII grossly normal.
vpe-abdomen
General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils. ENT: Hearing grossly intact. No nasal discharge.
Neck: Neck is supple. No masses or thyromegaly. Respiratory: Respirations are non-labored. No wheezing. Abdomen: Soft, non-tender, non-distended.
Skin: Warm. No rashes or ulcers.
29 statnote dot phrases - primary care phrase library
Psych: Alert and oriented. Cooperative, Appropriate mood and affect. Normal judgment.
CV: No lower extremity edema.
MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Sensation and CN 1I-X1I grossly normal.
,.pe-adult-cardiopuJm
General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
ENT: Hearing grossly intact. No nasal discharge. Oral mucosa is moist. Neck: Neck is supple. No masses or thyromegaly.
Respiratory: Respirations are non-labored. Lungs are clear to auscultation. Skin: Warm. No rashes or ulcers.
Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment.
CV: Normal heart sounds, no murmurs. No lower extremity edema. MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Sensation and CN II-X1I grossly normal.
,.pe-ent
General: No acute distress. Awake and conversant.
Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
ENT: Hearing grossly intact. No nasal discharge.
Clear tympanic membranes bilateral.
Pharyngeal erythema.
Neck: Neck is supple. No masses or thyromegaly.
Respiratory: Respirations are non-labored. No wheezing.
Skin: Warm. No rashes or ulcers.
Psych: Alert and oriented. Cooperative, Appropriate mood and affect. Normal judgment.
CV: No lower extremity edema.
MSK: Normal ambulation. No clubbing or cyanosis.
Neuro: Sensation and CN II-XII grossly normal.
30 statnote dot phrases - primary care phrase library
,.breast-PE
Breasts:
No chest deformity, asymmetry. Normal contours.
_Right breast: No dimpling, no breast tenderness, nodules or masses. No axillary adenopathy. No nipple discharge.
__Right breast: __lxl cm mass palpated at __3 OC, __4 cm from nipple. No nipple discharge. No axillary adenopathy.
,.pelvic-PE
Pelvic exam:
Labia: No erythema, No excoriation, No lesion.
Vagina: No bleeding. No discharge. No laceration.
Cervix: Os (Closed), No cervical motion tenderness, No discharge. Uterus: Mobile, Not tender.
Ovaries: Not tender.
,.rectal-PE
Rectal: normal sphincter tone, no anal, perineal or rectal lesions, prostate is not tender, enlarged or nodular.
,.testicular-PE
GU: Genital exam revealed normal uncircumcised penis. No penile lesions or penile discharge.
No scrotal edema or tenderness, no masses.
31 statnote dot phrases - primary care phrase library
2 CARDIOLOGY
,.afib
Atrial fibrillation On chronic anticoagulation. And rate control medications. Compliant. No side effects. Denies palpitations, CP, SOB.
,.afib#
# Wt and bili check Exam WNL.
<_8% wt loss.
Bili _low-risk level.
Encouraged continue breastfeeding.
212 statnote dot phrases - primary care phrase library
Precautions given for decreased PO intake, decreased wet diapers, fever> 100.4.
F/u in 2 wks for WCC.
,.wt+bili-check-PE
General: Awake and alert. No acute distress. Eye: Normal conjunctiva. No ictericia. Integumentary: Warm. Pink. No jaundice.
213 statnote dot phrases - primary care phrase library
13 PSYCHOLOGY
,.adhd
Patient c/o symptoms of inattention, impulsivity, and restlessness, resulting in functional impairment.
Reports symptoms since being adolescent.
No attention to details, difficulty sustaining attention, does not follow instructions, forgetful.
Often fidgets, unable to engage in leisure activities quietly, talks excessively, interrupts, difficulty waiting for his turn.
,.adhd#
# peripheral artery ds
36 statnote dot phrases - primary care phrase library
Anti platelet therapy.
Statins.
Exercise.
Optimal control of cardiovascular risk factors.
ABI < 0.8 - imaging and consider vascular sx referral.
,.pad-hpi
Pt c/o intermittent claudication.
Reports leg pain with walking that is relieved with rest.
,.pvd#
# peripheral artery ds Anti platelet therapy.
Statins.
Exercise.
Optimal control of cardiovascular risk factors.
ABI < 0.8 - imaging and consider vascular sx referral.
,.pvd-hpi
Pt c/o intermittent claudication.
Reports leg pain with walking that is relieved with rest.
,.score-ASCVD
10-year ASCVD calculated risk score <5%. No need for statins.
37 statnote dot phrases - primary care phrase library
3 DERMATOLOGY
,.accutane#
Discussed Remember not to give your medication to anyone else. Do not donate blood. Make sure you complete your comprehension questions on ipledge and pick up your medication within 7 days or you may end up being delayed in your treatment.
,.accutane#F
Discussed Maintain 2 forms of birth control or abstinence as discussed with your provider (during treatment and a month after). Remember not to give your medication to anyone else. Do not donate blood. Make sure you complete your comprehension questions on ipledge and pick up your medication within 7 days or you may end up being delayed in your treatment. Pregnancy test a month after the last dose.
vacne
Pt c/o facial acne.
38 statnote dot phrases - primary care phrase library
Using topicals w/o significant improvement. No scars.
Not affecting chest or back.
,.acne#
# right Lesion excised today and sent to pathology.
243 statnote dot phrases - primary care phrase library
Wound care instructions reviewed — pt. to keep it dry for first 24 hours, then may shower starting tomorrow evening.
Advised to change bandaid and reapply triple antibiotic ointment daily. F/u in 1 week for wound check and suture removal.
,.excisional-bx
Excisional biopsy Elliptical excision of right _ lesion.
Measuring _ cm.
Skin was cleaned with 70% alcohol swab.
Area was anesthetized with 1% lidocaine.
Area was prepped in usual sterile fashion with 10% iodine swab and sterile drapes. Sterile gloves were used.
Elliptical excision performed on lesion with 15-blade.
Lesion removed in its entirety with scalpel and Adson forceps.
Hemostasis achieved.
Intermediate repair: layered closure of subcutaneous tissue using 4-0 vicryl, _ sutures placed.
Complex repair: undermining of the skin on both sides of the surgical wound was done to loosen the tissues and close the defect created.
Wound closed with 4-0 nylon suture, _ simple interrupted sutures placed. Triple antibiotic ointment and bandaid applied.
Specimen sent to pathology
foreign-body-removal-proc
Location: right _ A foreign body embedded in subcutaneous tissue was identified.
Area was anesthetised using lidocaine 1 %. A simple incision in the skin overlying the foreign body was made. The foreign body was retrieved using hemostats/forceps. The skin was not sutured allowing to heal secondarily. Foreign body: _
244 statnote dot phrases - primary care phrase library
foreign-body-removal-simple*
10120
,.global-sx-period*
99024
hemorrhoid-external#
# vit D deficiency No risk factors.
Check 25-OH vit D, calcium.
Consider supplementation if <20.
Discussed sun exposure, Ca/vit D diet intake.
72 statnote dot phrases - primary care phrase library
5 ENT & OPHTHALMOLOGY
allergic-rhinitis
Pt c/o sneezing, nasal pruritus.
Some nasal congestion and rhinorrhea as well. Palate, throat, ear, and eye itching.
No eye redness.
allergic-rhinitis#
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