Appointment Progress Note Question & Answer Guide (With Explanation)

Understanding this question requires applying core subject principles.

What This Question Is About

This question relates to appointment progress note and requires a structured academic response.

How to Approach This Question

Break the problem into smaller parts and analyze each logically.

Key Explanation

This topic involves appointment progress note. A strong answer should include explanation, application, and examples.

Original Question

Appointment 2 Progress Note Patient Name: Mei Kimura Chief Complaint Patient presents for a follow-up visit for bipolar mood disturbance, stating, “My mood has been fine, but I don’t like the side effects I’m getting on it now (tremors and acne).” History of Present Illness/Interval History Since their last visit, their mood has been stable with medication and has not been interfering with their daily functioning. They complain of mild tremor in their hands and have developed acne, “I haven’t had breakouts like this since I was in high school.” Last lithium level from 3 days ago: 0.8mEq/L. Past Family/Social/Medical/Surgical History Last menstrual period: 2 weeks ago Surgeries: None Medical problems: None Social: Denies alcohol use, denies tobacco use, denies other illicit substance use Previously hospitalized inpatient for 2 weeks for manic episode (1 month ago) Denies prior medications Denies prior suicide attempts Current medications Lithium CR 450 mg, 2 tabs at bedtime Oral Contraceptive Pill Vital signs B/P: 122/84, HR: 76, Height: 5’5″, Weight: 150 pounds Review of Systems/Review of Symptoms Neurological: + tremors, – ataxia, – vertigo Dermatological: + acne, – rash, – wounds Psych: Denies manic symptoms, sleep is stable, reports compliance with medications

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