The gp_notes from pettypychen

COUGH X 2/7

A/W BN/RN AND ST
YELLOWISH PHLEGM
NO FEVER
NO RASH
NO TRAVEL HX
NO HAEMOPTYIS/LOW/LOA/SOB/WHEEZE
NO SX OF MENINGISM
NO CP/SOB/GIDDINESS
HOME ART NEGATIVE

ON EX:

ALERT NON-TOXIC AFEB

HS1S2 L CLEAR

PHARYNX MIN INJ TONSILS NAD NO EXUDATES

NO RASH

NECK SUPPLE ROM FULL NEUROLOGICALLY INTACT

IMP: URTI

PLAN: SYMP TX RETURN ADVICE RED FLAGS ADVISED FEVER ADVICE GIVEN TO SEEK MED ATTENTION IN EVENT OF FEVER >5 DAYS/RASH/SX OF MENINGISM/HAEMOPTYSIS/FEELING UNWELL/CP/SOB/GIDDINESS/PERSISTENT SYMPTOMS A&E ADVICE GIVEN MC X 1/7

ANAREX 2 TABS TDS X 20 TELFAST D 1 TAB BD X 10 COUGHEN 10ML TDS X 1 BOTTLE LEFTOSE 30MG BD X 10 MAC LOZ 1 TDS X 12 FLUIMUCIL 600MG OM X 5

EPIGASTRIC BLOATEDNESS X 2/7

A/W ON AND OFF BURNING ACHE AT EPIGASTRIUM, NO RADIATION
NO NAUSEA/VOMITING
NO FEVER/RASH
NO DIARRHEA
NO PR BLEED/MELENA
NO JAUNDICE/TEA COLOURED URINE/RHC PAIN
NO URINARY SX
NO CONST SX/EARLY SATIETY
NO CP/SOB/GIDDINESS

ON EX:

ALERT NON-TOXIC NO CONJ PALLOR MM MOIST AFEB

A SOFT, NON-TENDER, BS+, NO REBOUND OR GUARDING, NO MASSES

NO RASH

IMP: DYSPEPSIA LIKELY GASTRITIS

PLAN: PPI/ANTACID SYMP TX RETURN ADVICE RED FLAGS ADVISED ABDO PAIN ADVICE KIV UBT/GASTRO REF FOR SCOPES IF SX PERSISTENT PAST 2/52 MC X 1/7

OMEPRAZOLE 20MG BD X 10 MMT 10ML TDS X 1 BOTTTLE BUSCOPAN 10MG TDS X 10 DIMENATE 50MG TDS X 10

DIARRHEA X 1/7

WATERY AND BROWN
3 EPISODES
A/W GEN COLICKY ABDO PAIN, NO RADIATION OR LOCALIZATION
NO N/V
NO PR BLEED/MELENA
NO FEVER
TAKING WELL ORALLY
NO DIETARY INDESCRETION
NO TRAVEL HX
NO URINARY SX
NO JAUNDICE/TEA COLOURED URINE

ON EX:

ALERT NON-TOXIC AFEB MM MOIST

A SOFT, NON-TENDER. BS+, NO REBOUND OR GUARDING, NO MASSES

IMP: ENTEROCOLITIS

PLAN: SYMP TX RETURN ADVICE ABDO PAIN ADVICE RED FLAGS ADVISED MC X 1/7

LOPERAMIDE 2MG TDS X 10 BUSCOPAN 10MG TDS X 10 LACTEOL FORTE 1 SACHET TDS X 10 ORS 1 SACHET TDS X 10 DIMENATE 50MG TDS X 10

HEADACHE X 1/7

NO HI/LOC
MILD, NOT THUNDERCLAP, BITEMPORAL
NO FEVER/RASH
NO CP/SOB/GIDDINESS
NO FOCAL NEURO SX
NO BOV/NAUSEA/VOMITING/NECK STIFFNESS
NO AURAS
GAIT STEADY
DOES NOT GET DAILY MORNING HEADACHES
NO HX OF HTN

ON EX:

ALERT NON-TOXIC AFEB

GCS 15 PEARL 3MM EOMS INTACT NO NYSTAGMUS NO FACIAL ASYMMETRY SPEECH NAD MOVING ALL LIMBS WELL NO CEREBELLAR SIGNS NO PRONATOR DRIFT GAIT STEADY AMB WELL NEUROLOGICALLY INTACT

NECK SUPPLE ROM FULL

BP HR

IMP: NON-SPECIFIC HEADACHE

PLAN: ANALGESIA RETURN ADVICE MC X 1/7 RED FLAGS ADVISED ED ADVICE KIV NEURO REF IF HEADACHES RECURRENT/MORNING HEADACHES

ANAREX 2 TABS TDS X 20 ARCORIA 120MG OM X 5 OMEPRAZOLE 20MG OM X 5

GIDDINESS X 1/7

ACUTE ONSET
LIGHT HEADEDNESS/VERTIGINOUS
A/W NAUSEA, NO VOMITING
NO TINNITUS/HEARING LOSS/OTIC PAIN
NO BOV/NECK STIFFNESS/HEADACHE
NO CP/SOB
NO LOC/HI
NO FOCAL NEURO SX
NO FACIAL ASYMMETRY/SLURRING OF SPEECH
NO PR BLEED/MELENA/HAEMATURIA
NO ABDO PAIN/DIARRHEA
GAIT STEADY
NO FEVER/RECENT URTI
NOT WORSE ON TURNING HEAD OR ON POSTURAL CHANGE

ON EX:

ALERT NON-TOXIC MM MOIST NO CONJ PALLOR

HS1S2 PULSE REGULAR L CLEAR

GCS 15 PEARL 3MM EOMS INTACT NO NYSTAGMUS NO FACIAL ASYNMMETRY SPEECH NAD MOVING ALL LIMBS WELL NO CEREBELLAR SIGNS NO PRONATOR DRIFT GAIT STEADY AMB WELL NEUROLOGICALLY INTACT

BP HR

IMP: NON-SPECIFIC PERIPHERAL GIDDINESS

PLAN: SYMP TX MC X 1/7 RETURN ADVICE RED FLAGS ADVISED A&E ADVICE GIVEN

STEMETIL 10MG TDS X 10 CINNARIZINE 25MG TDS X 10 BETAHISTINE 24MG BD X 10

LOWER BACK PAIN X 2/7

MECHANICAL IN NATURE
CARRIED HEAVY LOADS THAT DAY
NO TRAUMA
NO FEVER/CONST SX
NO SCIATICA/RADICULAR SX
NO WEAKNESS/NUMBNESS
NO BOWEL OR BLADDER SX
NO URINARY SX/LOIN TO GROIN PAIN
AMBULATING WELL, NO GAIT ISSUES

ON EX:

ALERT NON-TOXIC AFEB

A SOFT, NON-TENDER, BS+, BILAT RENAL PUNCH NEG

L SPINE: NO CENTRAL STEP OR TENDERNESS NO PARAVERTEBRAL SPASM NO LISTING SLR NEG BILAT 70/70 L SPINE FROM POWER AND SENSATION IN LL INTACT IN ALL MYOTOMES/DERMATOMES GAIT STEADY AMBULATING WELL

IMP: LOWER BACK STRAIN

PLAN: ANALGESIA RETURN ADVICE BACK PAIN ADVICE GIVEN, RED FLAGS EXPLAINED KIV XR IN 5/7 IF NOT IMPROVING MC X 1/7

ANAREX 2 TABS TDS X 20 ARCOXIA 120MG OM X 5 OMEPRAZOLE 20MG OM X 5 VOREN GEL 1 APP BD X 1 TUBE

MENSTRUAL CRAMPS X 2/7

D2 MENSES
HAVING SUPRAPUBIC PAIN, SIMILAR TO PREV MENSTRUAL CRAMPS
NO EXCESSIVELY HEAVY MENSTRUAL BLEEDING, NOT MORE THAN 4 PADS A DAY, NO CLOTS
PERIODS USUALLY REGULAR 28-30 DAYS
NO FEVER
NO ABDO PAIN/DIARRHEA
NO URINARY SX
NO SX OF ANAEMIA

ON EX:

ALERT NON-TOXIC NO CONJ PALLOR AFEB

A SOFT, NON-TENDER, BS+, NO REBOUND OR GUARDING, NO PALPABLE UTERUS

IMP: PRIMARY DYSMENORRHOEA

PLAN: ANALGESIA RETURN ADVICE ABDO PAIN ADVICE RED FLAGS ADVISED MC X 1/7 KIV GYNAE REF IF SX WORSENING/EXCESSIVE BLEEDING

PARACETAMOL 1G QDS X 20 MEFANEMIC ACID 500MG TDS X 20 OMEPRAZOLE 20MG BD X 10 BUSCOPAN 10MG TDS X 10

EMERGENCY CONTRACEPTION

HAD UNPROTECTED INTERCOURSE WITH BOYFRIEND YESTERDAY NIGHT
LMP:
PERIODS USUALLY REGULAR 28-30 DAYS
CURRENTLY WELL
NO ABDO OR PELVIC PAIN/PV BLEED
NO HX OF CLOTS/HX OF THROMBOPHILIAS

ON EX:

ALERT NON-TOXIC

A SNT, BS+, NO REBOUND OR GUARDING, NO MASSES, NO PALPABLE UTERUS

CALVES SUPPLE, NIL EDEMA

IMP: EMERGENCY CONTRACEPTION

PLAN: POSTINOR/ELLA ADVISED ON SIDE EFFECTS OF MEDICATION (CLOT FORMATION, NEXT PERIOD DELAYED) RISK OF FAILURE ADVISED TO RETURN FOR UPT IF PERIOD DOES NOT ARRIVE WITHIN 1/52 OF EXPECTED ADVISED NOT TO TAKE REPEAT COURSE IN THE SAME MONTH CONTRACEPTION ADVISED RETURN ADVICE GIVEN RED FLAGS ADVISED

POSTINOR X 1 BOX

RASH ON TRUNK AND LIMBS X 2/7

ACUTE ONSET
ITCHY AND RED, RAISED LIKE MOSQUITO BITES
COMING AND GOING WITHIN 24 HRS
NO PIH
NO NEW DRUGS
NO FEVER/RECENT ILLNESS
NO CONST SX
NO INSECT BITES
NO IDENTIFIABLE TRIGGERS
NO FACIAL SWELLING/SOB/WHEEZE

ON EX:

ALERT NON-TOXIC AFEB

NO ANGIOEDEMA

L CLEAR

URTICARIAL WHEAL AND FLARE NOTED ON TRUNK AND LIMBS EXCORIATIONS + NO PIH MM CLEAR

IMP: ACUTE URTICARIA

PLAN: PRED X 5/7 ANTIHISTAMINES STRICTLY RETURN ADVICE RED FLAGS ADVISED KIV DERM REF IF NOT IMPROVING IN 2/52 DESPITE TX MC X 1/7

PREDNISOLONE 30MG OM X 30 TABS (5MG TABS) TELFAST 180MG OM X 10 ATARAX 10MG ON X 10

RIGHT EYELID SWELLING X 3/7

PAINFUL AND RED
GROWING BIGGER
NO FEVER/DISCHARGE
NO TRAUMA
NO BOV/PHOTOPHOBIA/OCULAR PAIN
NO CONTACTS USE

ON EX:

ALERT NON-TOXIC AFEB

VA GROSSLY INTACT PEARL 3MM EOMS INTACT CONJ AND CORNEAE GROSSLY NAD BILAT STYE/CHALAZION NOTED AT RIGHT UPPER EYELID, NO DISCHARGE NO PRESEPTAL CELLULITIS

IMP: STYE/CHALAZION

PLAN: XEPANICOL/FUCITHALMIC WARM COMPRESS ADVISED RED FLAGS ADVISED RETURN ADVICE GIVEN ED ADVICE GIVEN, FOR FURTHER OPHTHALMOLOGIC EVALUATION IF RED FLAGS DEVELOP MC X 1/7

DYSURIA X 2/7

A/W SUPRAPUBIC DISCOMFORT, NO RADIATION
NO LOIN OR BACK PAIN
A/W FREQUENCY AND URGENCY
NO HAEMATURIA
NO SMELLY OR CLOUDY URINE
NO BO SYMPTOMS/CHANGE IN BO HABITS
NO FEVER
NO ILICIT SEXUAL INTERCOURSE
NO HX OF RECURRENT UTI

ON EX:

ALERT NON-TOXIC AFEB

A SOFT, NON-TENDER, BS+, NO REBOUND OR GUARDING, NO PALPABLE BLADDER BILAT RENAL PUNCH NEG

UC9: BLOOD 2+ LEUK 3+ NITRITE NEG PRO NEG GLU NEG

IMP: UTI

PLAN: CIPRO/AUGMENTIN RED FLAGS ADV RETURN ADVICE ED ADVICE SYMP TX TO ED IF LOIN PAIN/NOT IMPROVING BY D3 ABX/PERSISTENT GROSS HAEMATURIA MC X 1/7

NECK PAIN X 1/7

SLEPT WITH POOR NECK POSITION
NO TRAUMA
NO FOCAL NEURO SX
NO FEVER
NO BOWEL OR BLADDER SX
NO GAIT ISSUES
NO RADICULAR SX

ON EX:

ALERT NON-TOXIC

C SPINE: NO CENTRAL STEP OR TENDERNESS TENDERNESS NOTED OVER SCM NECK SUPPLE ROM FULL LHERMITTES/HOFFMANS NEG SPURLINGS NEG NEUROLOGICALLY INTACT IN UL AND LL GAIT STEADY

IMP: NECK STRAIN

PLAN: ANALGESIA C SPINE XR IN 5/7 IF NOT IMPROVING RED FLAGS ADV BACK PAIN ADVICE MC X 1/7

BILATERAL RED EYES X 1/7

ITCHY AND RED
TEARY
NO FEVER/PURULENT DISCHARGE
NO TRAUMA
NO BOV/PHOTOPHOBIA/OCULAR PAIN
NO CONTACTS USE
NO FLOATERS/FLASHERS
NO URTI SX

ON EX:

ALERT NON-TOXIC AFEB

VA GROSSLY INTACT PEARL 3MM EOMS INTACT BILAT CONJUNCTIVA INJECTED + CORNEAE GROSSLY NAD BILATERALLY, NO OPACIFICATION/HYPOPYON NO STYE/CHALAZION/OCULAR ADNEXAL ABNORMALITIES

IMP: CONJUNCTIVITIS

PLAN: ISOLATION ADVISED MO FLOREN PATANOL RED FLAGS ADVISED RETURN ADVICE GIVEN ADVISED AGAINST CONTACT LENS USE ED ADVICE GIVEN, FOR FURTHER OPHTHALMOLOGIC EVALUATION IF RED FLAGS DEVELOP MC X 1/7

RIGHT ANKLE PAIN X 1/7

TWISTED ANKLE
INVERSION INJURY
NOW HAS MECHANICAL PAIN AT LAT ASPECT OF ANKLE
A/W SWELLING AT LATERAL ASPECT OF ANKLE
STILL ABLE TO AMBULATE AND WEIGHT BEAR
NO OTHER INJURIES
NO WEAKNESS/NUMBNESS
NO PALLOR/DUSKINESS
NO KNEE OR FOOT PAIN

ON EX:

ALERT NON-TOXIC

RIGHT ANKLE: NO GROSS DEFORMITIES SOFT TISSUE SWELLING OVER OVER LATERAL ASPECT OF ANKLE TENDERSS + NOTED OVER SOFT TISSUES OF LATERAL ASPECT OF ANKLE NO BONY TENDERNESS NO TIB/FIB/MALLEOLAR/BASE OF 5TH MT/NAVICULAR TENDERNESS ANKLE FROM NV INTACT, DP AND PT ++, CRT<2S ABLE TO WB >4 STEPS ON INJURED LEG GAIT ANTALGIC

IMP: RIGHT ANKLE SPRAIN

PLAN: XR IN 3/7 IF PAIN PERSISTENT/NOT IMPROVING RED FLAGS ADV ANALGESIA RICE RETURN ADVICE MC X 1/7

DERM HISTORY TAKING Shaping Letters Into Words: Further Charaderization of Identified Lesions • Color Pink, red, purple (purpuric lesions do not blanch with pressure with a glass slide [diascopy]), white, tan, brown, black. blue, gray, and yellow. The color can be uniform or variegated. • Margination Well (can be traced with the tip of a pencil) and ill defined. • Shape Round, oval, polygonal. polycyclic, annular (ring-shaped), iris, serpiginous (snakelike), umbilicated • Palpation Consider (1) consistency {soft, firm, hard, fluctuant, boardlike), (2) deviation in temperature (hot, cold), and (3) mobility. Note presence of tenderness, and estimate the depth of the lesion (i.e., dermal or subcutaneous). Forming Sentences and Understanding the Text: Evaluation of Arrangement,Patterns, and Distribution • Number Single or multiple lesions. • Arrangement Multiple lesions may be (1) grouped: herpetifonn, arciform, annular, reticulated (net-shaped), linear, serpiginous (snakelike) or (2) disseminated: scattered discrete lesions. • Confluence Yes or no. • Distribution Consider (1) extent: isolated (single lesions), localized, regional, generalized, universal. and (2) pattern: symmetric, exposed areas, sites of pressure, intertriginous area, follicular localization. random,following dennatomes or Blaschko lines.

HX Demographica Age, race, sex, and occupation

Constitutional symptoms: Acute illness" syndrome: headaches,chills, feverishness, and weakness. chronic illness" syndrome: fatigue, weakness, anorexia, weight loss, and malaise.
History of skin lesions. key questions: • When t Onset • Wheret Site of onset • Does it itch or burtt Symptoms • How has it spread (pattern of spread)t Evolution • How have individual lesions changedt Evolution • Provocative factorst Heat, cold, sun, exercise, travel history, drug ingestion, pregnancy, season o Previous treatment(s)t Topical and systemic 3 . General history of present illne111 aa indicated by clinical situation, with particular attention to conatitutional and prodromal symptoms.
Put medical hiatory: • Operations • Illnesses (hospitalizedt) • Allergies, especially drug allergies • Medications (present and past) • Habits (smoking, alcohol intake, drug abuse) • Atopic history {asthma, hay fever, eczema)
Family medical history (particularly of psoriasis, atopy, melanoma, xanthomas, tuberous sclerosis).
Social hiatory, with particular reference to occupation, hobbies, exposure, travel, or injecting drug use.
Sexual history: histury of risk factors of mv: blood transfusions, IV clrup, sexually active, multiple partners, STDs