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1、Note for Jane Doe on 4/4/03 - Chart 10Chief Complaint: This 31 year old female presents today for evaluation of seizure activity witnessed by others.Associated signs and symptoms: Associated signs and symptoms include headache with intractable pain, muscle jerking and numbness.Duration: Condition ha
2、s existed for 4 months.Modifying Factors: Patient indicates no modifying factors.Quality: Quality of the pain is described by the patient as episodic and intermittent. Severity: Severity of condition is moderate. The severity has worsened over the past 2 months.Allergies: Patient admits allergies to
3、 peanuts resulting in shortness of breath, severe rash, GIintolerance.Medication History: Patient is currently taking Ak-spore Ointment 4000 u-3.5 mg-10000 u/gm ointment (BID) medication was prescribed by A. Ophthalmologist, Alesse-28 20 mcg-0.10 mg tablet(QD) medication was prescribed by A. Obstetr
4、ician-Gynecologist. Past Medical History: Past medical history is unremarkable. PSH: No previous surgeries.Social History: Patient denies smoking, alcohol abuse, illicit drug use and STDs.Family History: Patient admits a family history of alcoholism associated with paternal grandfather, and heart pr
5、oblems associated with father (deceased).Review of Systems: Neurological: (+) confusion (+) forgetfulness (+) uncontrolled movements Hematologic / Lymphatic: (+) sweats Constitutional Symptoms: (+) headache Psychiatric: (+) disorientation Neurological: (-) paralysis Hematologic / Lymphatic: (-) anem
6、ia Allergic / Immunologic: (-) seasonal allergies Constitutional Symptoms: (-) dizziness (-) anxiety (-) faintness Cardiovascular: (-) shortness of breath (-) loss of time (-) chest pain Respiratory: (-) breathing difficulties, respiratory symptomsPhysical Exam: BP Standing: 120/94 Resp: 19 HR: 82 H
7、eight: 5 ft. 8 in. Weight: 132 lbs. Patient is a31 year old female who appears somewhat tired and breathing comfortably.HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. No nuchal rigidity. Thyroid examination reveals no abnormalities.
8、 Fundoscopic Exam: Bilateral retinas reveal normal color, contour, and cupping. Bilateral retinas reveals clear.Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, no edema andpuls
9、es are full to palpation. Carotid pulses are palpated with no bruits auscultated over the carotid and vertebral arteries.Neurological Exam:Mental Status: Stream of thought is spontaneous, abstract thought is intact and serial 3s and simple calculations are intact. Speech is appropriate with regular
10、rate and rhythm. Recent and remote memory is poor. Attention span and concentration is good. Patient awareness of current events, past history and vocabulary is good.Cranial Nerves: CNs III, IV, VI reveal no deficits and pupils as equal round and reactive to direct and consensual light. CN II reveal
11、s visual fields full to confrontation. CN V shows no deficits and facial sensation intact in all three distributions of the trigeminal nerve. CN VII shows muscles of facial expression are intact and symmetric. CN XII shows tongue protrudes midline without deviation or tremor. CN X reveals gag reflex
12、 intact and symmetrical elevationof soft palate to phonation. Rinnes test shows no abnormalities. Webers test shows no abnormalities. CN VIII shows normal hearing. CN XI shows sternocleidomastoid and trapezius muscles are symmetric and 5/5 in strength.Motor Exam: Muscle tone is normal. Muscle streng
13、th is 5/5 for all groups tested.Sensory Exam: Touch, pin, vibratory and proprioception sensations are normal. Rombergs test is negative.Reflexes: Bilateral brachioradialis reflex, bilateral patellar reflex, bilateral Achilles reflex, bilateral biceps reflex and bilateral triceps reflex is 2/4. Ankle
14、 clonus, Hoffmans sign, Tromner sign and Babinski reflex is absent. Frontal lobe signs glabellar, bulldog, root, snout, palmomental and grasp are not elicited.Cerebellar Exam: Coordination is normal for finger/nose testing, normal for heel/knee/shin testing, normal for rapid alternating movements an
15、d negative for truncal or gait ataxia. Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking.Test Results: EEG shows normal frequency, amplitude, and characteristics of brain waves. CT scan of the brain reveals no evidence of disease.Impression: Epileptic con
16、vulsions, fits, seizures unspecified.Plan: EEG performed: awake and asleep. Ordered CT scan of the cervical spine without then with contrast and head or brain with contrast. Jane was counseled the importance of finishing all medications prescribed and the importance of compliance with chosen treatme
17、nt options. Return to clinic in 2 week(s).Prescriptions:Neurontin Dosage: 100 mg capsule Sig: BID Dispense: 30 Refills: 0 Allow Generic: No_ A. Neurologist, MDSample Referral Letter Charting Plus - Electronic Medical R4/4/03Marcus Welby, M.D.1231 8th Street, Suite 222West Des Moines, IA 50265Dear Dr
18、. Welby:Jane Doe was seen in my office in consultation as requested by you as a new patient for evaluation and care. The following is a summary of my findings and recommendations:Chief Complaint: This 31 year old female presents today for evaluation of seizure activity witnessed by others.Associated
19、 signs and symptoms: Associated signs and symptoms include headache with intractable pain, muscle jerking and numbness.Duration: Condition has existed for 4 months.Modifying Factors: Patient indicates no modifying factors.Quality: Quality of the pain is described by the patient as episodic and inter
20、mittent. Severity: Severity of condition is moderate. The severity has worsened over the past 2 months.Allergies: Patient admits allergies to peanuts resulting in shortness of breath, severe rash, GIintolerance.Medication History: Patient is currently taking Ak-spore Ointment 4000 u-3.5 mg-10000 u/g
21、m ointment (BID) medication was prescribed by A. Ophthalmologist, Alesse-28 20 mcg-0.10 mg tablet(QD) medication was prescribed by A. Obstetrician-Gynecologist. Past Medical History: Past medical history is unremarkable. PSH: No previous surgeries.Social History: Patient denies smoking, alcohol abus
22、e, illicit drug use and STDs.Family History: Patient admits a family history of alcoholism associated with paternal grandfather, and heart problems associated with father (deceased).Review of Systems: Neurological: (+) confusion (+) forgetfulness (+) uncontrolled movements Hematologic / Lymphatic: (
23、+) sweats Constitutional Symptoms: (+) headache Psychiatric: (+) disorientation Neurological: (-) paralysis Hematologic / Lymphatic: (-) anemia Allergic / Immunologic: (-) seasonal allergies Constitutional Symptoms: (-) dizziness (-) anxiety (-) faintness Cardiovascular: (-) shortness of breath (-)
24、loss of time (-) chest pain Respiratory: (-) breathing difficulties, respiratory symptomsPhysical Exam: BP Standing: 120/94 Resp: 19 HR: 82 Height: 5 ft. 8 in. Weight: 132 lbs. Patient is a31 year old female who appears somewhat tired and breathing comfortably.HEENT: Inspection of head and face show
25、s head that is normocephalic, atraumatic, without any gross or neck masses. No nuchal rigidity. Thyroid examination reveals no abnormalities. Fundoscopic Exam: Bilateral retinas reveal normal color, contour, and cupping. Bilateral retinas reveals clear.Cardiovascular: Normal S1 and S2 without murmur
26、s, gallop, rubs or clicks. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, no edema andpulses are full to palpation. Carotid pulses are palpated with no bruits auscultated over the carotid and vertebral arteries.Neurological Exam:Mental Status: Strea
27、m of thought is spontaneous, abstract thought is intact and serial 3s and simple calculations are intact. Speech is appropriate with regular rate and rhythm. Recent and remote memory is poor. Attention span and concentration is good. Patient awareness of current events, past history and vocabulary i
28、s good.Cranial Nerves: CNs III, IV, VI reveal no deficits and pupils as equal round and reactive to direct and consensual light. CN II reveals visual fields full to confrontation. CN V shows no deficits and facial sensation intact in all three distributions of the trigeminal nerve. CN VII shows musc
29、les of facial expression are intact and symmetric. CN XII shows tongue protrudes midline without deviation or tremor. CN X reveals gag reflex intact and symmetrical elevation of soft palate to phonation. Rinnes test shows no abnormalities. Webers test shows no abnormalities. CN VIII shows normal hea
30、ring. CN XI shows sternocleidomastoid and trapezius muscles are symmetric and 5/5 in strength.Motor Exam: Muscle tone is normal. Muscle strength is 5/5 for all groups tested.Sensory Exam: Touch, pin, vibratory and proprioception sensations are normal. Rombergs test is negative.Reflexes: Bilateral br
31、achioradialis reflex, bilateral patellar reflex, bilateral Achilles reflex, bilateral biceps reflex and bilateral triceps reflex is 2/4. Ankle clonus, Hoffmans sign, Tromner sign and Babinski reflex is absent. Frontal lobe signs glabellar, bulldog, root, snout, palmomental and grasp are not elicited
32、.Cerebellar Exam: Coordination is normal for finger/nose testing, normal for heel/knee/shin testing, normal for rapid alternating movements and negative for truncal or gait ataxia. Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking.Test Results: EEG shows
33、normal frequency, amplitude, and characteristics of brain waves. CT scan of the brain reveals no evidence of disease.Impression: Epileptic convulsions, fits, seizures unspecified.Plan: EEG performed: awake and asleep. Ordered CT scan of the cervical spine without then with contrast and head or brain
34、 with contrast. Jane was counseled the importance of finishing all medications prescribed and the importance of compliance with chosen treatment options. Return to clinic in 2 week(s).Prescriptions:Neurontin Dosage: 100 mg capsule Sig: BID Dispense: 30 Refills: 0 Allow Generic: NoIf I may be of any
35、further assistance in the care of your patient, please let me know. Thank you for providing me the opportunity to participate in the care of your patients.Sincerely,A. Neurologist, MDSample Prescription Charting Plus - Electronic Medical RA. Neurologist, MDDEA#:_Name: Jane Doe Date: 4/4/03Addr: 1231
36、 8th Street, Suite 222West Des Moines, IA 50265_Neurontin100 mg capsuleBIDX_ X_ Substitution Permitted Dispense as writtenRefills: 0Disp: 30Allow Generic: NoSample Billing Statement Charting Plus - Electronic Medical RBilling Statement - Friday, April 04, 2003Provider: A. Neurologist, MDPatient: Jan
37、e Doe, Chart 101231 8th Street, Suite 222West Des Moines, IA 50265Diagnoses1. 345.91 Epilepsy, Unspecified, With Intractable EpilepsyTreatments1. 99213 Office or other outpatient visit - est. patient - 15 min. Related Diagnoses: 345.91Modifiers: Units:2. 95819 Electroencephalogram (EEG) Including Re
38、cording A wake And Asleep (IncludingHyperventilation And/or Photic Stimulation When Appropriate) Related Diagnoses: 345.91Modifiers: Units:Referring Physician: Marcus Welby, M.D.Date Last Seen: 07/27/2001Sample Patient Instruction Charting Plus - Electronic Medical RPatient Instructions for Jane Doe
39、 on 4/4/03ALZHEIMERS DISEASEWhat is it?Alzheimers disease, also known as presenile dementia, is a brain disorder characterized by gradual mental deterioration. There are two kinds; a rapidly progressing form that appears around 36 -45 year of age and a gradual form with slow development that appears
40、 around 65 -70 years of age. The cause is unknown but leads to irreversible damage to brain cells. Heredity may play a role. There is no prevention for this disease. It is incurable and treatment will only help relieve the symptoms.Signs and symptoms:Early:* Forgetfulness of recent events.* Increase
41、d difficulty with usual activiti es of daily living, such as work, balancing a checkbook or running a household.* Personality changes.* Poor impulse control and judgment.Later:* Difficulty with simple tasks such as coordinating and choosing clothing or solving problems.* Familiar people arent recogn
42、ized.* Poor hygiene and appearance.* Difficulty feeding self.* Belligerence.* Denial of any problems.* Loss of sexual inhibitions.* Wandering, getting lost.* Anxiety.* Insomnia.Advanced:* Complete memory loss.* N o speech or muscle function.* Loss of bladder and bowel control.* Extreme belligerence
43、and hostility.Alzheimers causes decreased resistance to infections, especially pneumonia and meningitis. Seizures and coma can occur but are rare.Treatment:* Dont take a friend or family members hostility personally if they have Alzheimers.* Make sure the home is a safe environment.* If you care for
44、 an Alzheimers patient at home, dont feel guilty for asking for help and getting away once and a while. Take a break often.* Join or start up a support group for family members of Alzheimers patients.* Give frequent simple reminders to help memory problems.* Reassure an anxious or agitated patient w
45、ith a brief, direct conversation.* Distract those Alzheimers patients who are frustrated or agitated with another activity such as a walk.* Discontinue other medications if possible if they cause confusion or sedation.* New prescription drugs may help delay Alzheimers from progressing.* Encourage patient activity as much as possible; eventually they will need supervision for all activity.* A regular diet is appropriate, but patients will need help with feeding in the later and advanced stages of the disease._ A. Neurologist, MD