Dashboard
-
Origination
| Notes | Grading Score | Status | |
|---|---|---|---|
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed |  |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed | |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed | |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed | |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 0 | Created | |
| Below is the reformatted clinical note based solely on the provided information: -- Reformatted Clinical Note Patient Information - Name: Jordan - Provider: Dr. Monroe Chief Complaint - Reports feeling a sense of dread upon waking, experiencing low mood, exhaustion, and increased alcohol consumption. History of Present Illness (HPI) - Onset: Several months ago - Duration: Persistent depressive feelings and exhaustion over months - Character: Describes an ongoing low mood and a sense of dread in the mornings; forces themselves through work only to collapse later with alcohol use - Associated symptoms: Reports physical and mental exhaustion, not finding activities enjoyable, and feelings of hopelessness - Aggravating Factors: Daily routine, work stress (implied by the description of forced productivity) - Relieving Factors: No specific strategies mentioned; notes only supportive therapeutic environment - Timing: Most days upon waking and throughout the day - Severity: Significant impairment noted by the patient as disrupting work and personal life - Narrative: The patient explains a cyclical pattern of forcing themselves to complete work in the morning, culminating in excessive alcohol use later as an attempt to cope. They acknowledge that their drinking habits have worsened and that activities they once enjoyed no longer bring satisfaction. Past Medical History (PMH) - Not provided Review of Systems (ROS) - Not formally documented; notable positive symptoms include: - Depressive mood - Fatigue (mental and physical) - Increased alcohol consumption Physical Examination - Vital Signs: Not documented - Pertinent Findings: The supportive interaction during the session indicates that the patient feels comfortable sharing their feelings, but no formal physical exam details were noted. Assessment / Diagnosis - Clinical Findings: - Significant depressive symptoms including persistent low mood, fatigue, and feelings of dread. - Increased alcohol consumption, which the patient acknowledges has worsened. - Clinical Reasoning: - Given the persistent depressive symptoms (low mood, mental and physical exhaustion) over several months combined with problematic alcohol use, the presentation is concerning for major depressive disorder and alcohol use disorder. Plan / Treatment - Continue to explore the patient's mood and coping mechanisms in future sessions. - Discuss potential strategies for managing alcohol consumption and addressing depressive symptoms. - Schedule a follow-up appointment to monitor progress and adjust the treatment plan as necessary. Additional Documentation - Informed Consent: Not documented - Risk Assessment: Not documented - Provider Signature/Date: Not documented -- Quality Grade: High Additional Questions for Improvement: 1. Would you like to include any laboratory or diagnostic test results if available? 2. Should additional details from the physical examination or vital signs be incorporated if they become available? 3. Are there any specific templates or fields you would like to add or adjust in the documentation format? | 4 | Completed | |
| **SOAP Clinical Notes** **S: Subjective** - Patient reports feeling exhausted both mentally and physically, stating they have been feeling low for months. They express concern about their drinking habits, indicating it has gotten out of hand again. - The patient describes their mood as heavy, stating that even the idea of leaving the house feels burdensome. They mention that most days they wake up dreading the day, forcing themselves through work, and then crashing on the couch with a bottle. They feel that nothing is enjoyable anymore. - The patient experiences racing thoughts about bills, job security, and feelings of having messed up their life. They report pacing or fidgeting, especially in the evenings, and describe their energy level as heavy. - Sleep is affected; the patient usually falls asleep after drinking but wakes up at 3:00 AM with a racing heart and mind, unable to return to sleep. They acknowledge that worries return louder even when they try to relax. - The patient admits to using alcohol to calm their nerves, stating they consume a six-pack most nights, sometimes with whiskey on weekends, and often lose count. **O: Objective** - The patient appears fatigued and expresses feelings of anxiety and depression. They demonstrate insight into their drinking habits and acknowledge the impact on their daily life and sleep patterns. **A: Assessment** - The patient is experiencing symptoms consistent with anxiety and depression, exacerbated by increased alcohol consumption. Their self-reported feelings of dread, racing thoughts, and physical symptoms (e.g., racing heart, stomach knots) suggest a significant level of distress. **P: Plan** - Continue to monitor the patient's mood and alcohol consumption. - Discuss potential coping strategies for managing anxiety and depressive symptoms. - Explore options for reducing alcohol intake and addressing underlying issues contributing to the patient's mental health concerns. - Schedule a follow-up appointment to reassess mood, anxiety levels, and alcohol use. | 4 | Completed | |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed | |
| Patient Name: John Doe Age: 24 Sex: Male Date: 2025-07-08 MRN: 1002958 Chief Complaint: Abdominal pain for the past 24 hours. History of Present Illness (HPI): The patient is a 24-year-old male who presents with right lower quadrant abdominal pain that began approximately 24 hours ago. Initially described as vague and peri-umbilical, the pain has since localized to the right lower quadrant and increased in intensity. He also reports nausea, one episode of vomiting, and a low-grade fever. Denies diarrhea or urinary symptoms. No previous history of similar episodes. Past Medical History: No significant past medical history No previous abdominal surgeries Medications: None Allergies: NKDA (No Known Drug Allergies) Review of Systems: General: Mild malaise, subjective fever GI: Nausea, vomiting, RLQ pain, no diarrhea or constipation GU: Denies dysuria, hematuria Other systems: Negative Vital Signs: Temp: 100.6°F (38.1°C) HR: 96 bpm BP: 124/78 mmHg RR: 18 SpO₂: 98% on room air Physical Examination: General: Alert and oriented, appears mildly uncomfortable Abdomen: RLQ tenderness with rebound and guarding Positive McBurney's point tenderness Rovsing's sign positive Bowel sounds present, no masses or organomegaly Other systems: Normal Labs/Imaging: CBC: WBC: 13,200 /μL (elevated) Neutrophils: 80% CRP: Elevated Urinalysis: Normal Abdominal Ultrasound: Inconclusive CT Abdomen with contrast: Dilated appendix with wall thickening, periappendiceal fat stranding consistent with acute appendicitis Assessment: Acute appendicitis Plan: NPO Start IV fluids (normal saline) Start IV antibiotics (ceftriaxone + metronidazole) Surgical consultation for laparoscopic appendectomy Pain management with acetaminophen/IV morphine as needed Monitor vitals and abdominal exam closely Consent for surgery obtained | 5 | Completed | |