Clinic Progress Note Explained for Students (Easy Guide)

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Original Question

Clinic Progress Note, Well Child Care Three months later, Leah again is brought to the clinic by her mother. The first-listed diagnosis is the otitis media, but you will also need to report a Z code to indicate that the purpose of this visit was a medical examination for admission to preschool. LOCATION: Outpatient, Clinic PATIENT: Leah Charles PHYSICIAN: Rita Wimer, MD SUBJECTIVE: The patient is an almost 4-year-old girl who presents to the clinic with her parents for well child care and Head Start physical. Mother states that she was seen 1 month ago when they noted fluid in one of her ears. Mother does not notice any problems with the patient’s hearing or speech development. She has not had a runny nose, cough, or fever. She eats well from the four food groups and has no problems with constipation or diarrhea. OBJECTIVE: On general appearance, the patient is alert and does not appear to be in any acute distress. Temperature is 97.7° F. Weight is 15.8 kg (kilogram), which places her right at the 50th percentile. Height is 97.8 cm (centimeter), which places her right beneath the 25th percentile. Blood pressure is 90/60. HEENT (head, ears, eyes, nose, throat): PERRLA (pupils equal, round, reactive to light and accommodation). EOMI (extraocular movement intact). Discs are sharp. Right TM does have some fluid present behind it. The left TM is nice and clear. Oropharynx is unremarkable. Neck is supple. Heart reveals a regular rate and rhythm. Lungs are clear to auscultation bilaterally, and her abdomen is soft. GU (genitourinary): Normal female genitalia. Extremities have full range of motion. Back reveals a straight spine. Hearing was checked and is normal bilaterally. Vision is 20/25 bilaterally. IMPRESSION: Female almost 4 years old with right serous otitis media. PLAN: I recommended following up with the patient in 2 months to ensure that the fluid has gone. Prescribed amoxicillin, 20 mg (milligram), q.8h. (every 8 hours). If it has not at that point, we may need to look into further ways of management. Mother was in agreement with this. SERVICE CODE(S): ______________________________________ ICD-10-CM DX CODE(S): ________________________

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