Clean This Medical Question & Answer Guide (With Explanation)
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Original Question
clean up this HnP medical note please. : CC: Patient presents for follow up exam.HPI: Pt coming in for a check up today with complaints of a headache which has lasted 7 days. He says it is generalized on top of his head. The headaches last all day and nothing makes them better or worse. He reports numbness in his fingers and neck which is not new, he follows with neuro surgery for these symptoms. ROS:Const: Denies chills and fever.ENMT: Denies mouth or throat symptoms.CV: Denies chest pain.Resp: Denies SOB.GI: Denies diarrhea, nausea and vomiting.GU: Urinary: denies dysuria and incontinence.Musculo: Denies joint pain.Skin: Denies rash.Neuro: Reports constant headache and numbness/tingling in bilateral hands. Psych: Denies depression. Current Meds: Celecoxib 200 mg, Atorvastatin Calcium 20 mg, Freestyle Libre 2/Sensor/Flash Glucose Monitoring System 2 Sensor, Freestyle Libre 2/Reader/Flash Glucose Monitoring System 2 Reader, Omeprazole 20 mg, Soliqua 100-33 unt-mcg/ml, BD Pen Needle/Mini/Ultra-Fine/31G X 5mm 31G X 5 mm, Metformin HCL 1000 mg, Tizanidine HCL 4 mg, Cephalexin 500 mg, Gabapentin 300 mgAllergies: NKDA PMH:Immun/Inj. Record:90750-Shingrix Zoster Vaccine (HZV), Recombinant, Subunit, Adjuvante 00/00/00U-Tetan-Tetanus,Unspecified 01/01/16J1100-Injection Dexamethasone Sodium Phosphate, 1 MG 07/27/23 07/27/2391301-Covid-19 Moderna vaccine, mRNA, LNP-S, PF, 100 mcg/ 0.5 mL 05/07/21 03/31/21.Health Maintenance:Eye Exam – LONG TIME AGO Dental Exam – DENTURESColon
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