|
HPI
|
|
|
Gradual. No triggers or factors that change sx
|
Location of pain
• • •
|
|
Onset: *
• • •
|
|
|
Emesis is nonbloody.
|
Moderate. Nonradiating. No fevers.
|
|
No urine changes, vaginal bleeding or discharge
|
Associated symptoms.
• • •
|
|
Chronic sx. Similar to prior episodes.
|
No hx of GERD or abdominal surgeries.
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
GI sx (positive)
• • •
|
GI sx (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
ABD: Flat. Soft. N/T. No peritoneal signs
|
|
|
Abodmen macros
• • •
|
Abdomen - No___
• • •
|
|
Additional
|
|
|
PE: Superficial
|
PE: Head to toe exam
|
|
Insert Macro Here
|
|
|
|
|
|
MDM
|
Clinic Visit CPT CODE***
|
|
DDx: vomiting vs diarrhea vs pancreatitis vs diverticulitis vs appendicitis vs colitis vs cholecystitis vs constipation
|
MDM Notes
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Referred to GI specialist
|
|
Plan Notes
|
|
|
Discharge pt home
|
Discharge Note: ERD ONLY
|
