Clinical note · #8
Office & outpatient
Provider: Dr. Last Name, First Name, MD
Date: 10/26/2023
Patient Information
Name: John Johnson
Date of Birth: 08/18/1955
Sex: Male
Medical Record Number: 765432109
Chief Complaint
Mr. Johnson's chief complaints include ongoing nausea and vomiting attributed to gastroparesis related to his diabetes. He experiences unpredictable episodes of vomiting after eating without specific food triggers. Zofran has been effective in providing relief when taken. In addition, he reports vertigo triggered by head movement and positional changes.
Medical History:
Mr. Johnson has a history of diabetes, which is contributing to his gastroparesis. He has experienced recurrent nausea and vomiting associated with this condition.
Objective Findings:
Upon examination:
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Mr. Johnson is lying flat in bed, watching television, and is pleasant and conversational.
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He demonstrates good recall and communication skills, although he speaks quietly.
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No abnormalities found during head, eyes, ears, nose, and throat (HEENT) examination.
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Clear lung sounds.
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Cardiac examination reveals a regular rate and rhythm.
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Abdomen is soft, non-tender, with normal bowel sounds and no distension.
Assessment and Plan
1. Gastroparesis:
- Initiate a trial of Zofran (ondansetron) 4 mg orally three times a day (TID) for 10 days to manage nausea and vomiting due to gastroparesis.
- Monitor for signs of improvement in symptoms.
2. Benign Paroxysmal Positional Vertigo:
- Consider a trial of meclizine 12.5 mg orally three times a day (TID) for 10 days to address vertigo triggered by head movement and positional changes.
- Monitor for improvement in vertigo symptoms.
3. Follow-up:
- Schedule a follow-up appointment in 10 days to assess the patient's response to the prescribed treatments.
Signed by the provider · 10/26/2023