Clinical note · #3
Office & outpatient
Patient: John Smith · DOB: mm/dd/1985 · Date of visit: 10/26/2023
Chief complaint: Fatigue
History: The patient is a 38-year-old male who presents with complaints of fatigue for the past 3 days. He denies any recent injuries, fever, or rashes. No significant medical history reported.
ROS: Denies all systems as per mother (independent historian).
Physical examination: General: patient appears fatigued. Vital signs within normal limits. Musculoskeletal: no swelling. No other significant findings.
Assessment and plan: Fatigue, possibly due to minor musculoskeletal strain. No evidence of severe systemic disease at this time. Recommended rest, acetaminophen 500 mg q6h PRN, and follow-up in two weeks if symptoms persist.
Electronically signed by Tera, John, PA 09/26/2023