HPI: The patient presents for annual physical. 
She is due for her Tdap which she will receive today in clinic.
She will have her Pap today. She was sexually active in the past but not currently. Her last menstrual period was middle of 07/2023. She is G0P0. Reports irregular menses, was on the depo shots and states that her menses were regular before she was on the shots. 

Her thyroid panel done in 06/2023 showed a high TSH of 10.720 and a normal free T4 of 1.3. I started her on the levothyroxine 50 mcg 1 daily. She unfortunately did not pick up her thyroid medication. Advised starting on the medication. No blood work will be repeated today; it will be rechecked in 6 weeks’ time and orders provided today. 
She has gained 3 pounds since her last visit, current weight of 198 pounds, reports working 5 days a week 12-hour shifts and pretty much sleeps on her off days. 
Of note the patient checked feeling down, depressed, hopeless nearly everyday on her PHQ9 questionnaire. She did not mention this during our interview. My nurse pointed this out to me. I went and talked to her again about this and she admits to feeling down and depressed often and would like to try medication for it. Denies any SI or HI. 

She follows at America’s Best for eye examinations; last eye examination was beginning of the year. She got her glasses in February. Her visual acuity in clinic today was OS 20/100, OD 20/70 and OU 20/50. 

Denies sleep issues, denies chest pain, palpitations, shortness of breath, abdominal pain, bowel or bladder complaints. 
PE: Overweight. 

A and P:
Given her script for escitalopram 10 mg 1 daily. Advised it will take 4-6 weeks to be effective. Most common side effects can be nausea and fatigue and advised taking at dinner time.
Also encouraged her to set up appointment with a mental health therapist, handout for names of the therapists were provided today and she was encouraged to call and set up appointment with them.
She is aware if she has any problems or concerns prior to her next appointment to call. She denies any negative thoughts or thoughts of self harm. 
Name: Shian

CC:

HPI: : Patient presents with complaint of panic attacks x 2 weeks ago she states she had 2 episodes of chest tightness,SOB,felt she could not catch her breathe when she was at work she states she was very stressed out at work when symptoms started. She only takes hydroxyzine but avoids taking it during the day as it makes her feel sleepy. Reports increase in episodes of panic attacks of late. Follows with a therapist via telehealth every 2 weeks. She works full time does 2 jobs and has 2 kids at home and is stressed out. Her husband also does 2 jobs. Reports feeling nervous and anxious on a daily basis, denies any element of depression. She has not taken any preventative medication ever only has gone along with as needed mediations. Denies any SI or HI. 
The patient was hesitant to start on a preventative medicine; was wary about the fact that she become dependent on it. She wanted my opinion on this. I did advise her to start taking a daily medication and if in the future her symptoms improve we can taper her off of the medicine. Cautioned patient to stop mental health medications cold turkey. She finally agrees to try on a medicine. 

PE:

A and P:
I started her on Lexapro 10 mg 1 daily. 
It will take about 4-6 weeks to be effective.
Common side effects includes drowsiness and nausea and hence advised to take it at dinnertime.
Continue on the hydroxyzine as needed and also continue follow up with the mental health therapist. 
She is aware if she has any problems or concerns prior to her next appointment to call. She denies any negative thoughts or suicidal ideations.

Name: s

CC:

HPI: Patient presents with right knee pain. He was playing soccer and collided with another player, stumbled and did not fall. This happened on 08/31. He played the rest of the game, continued to run. He then sat down for 10 minutes and felt soreness and stiffness to his left knee. Reports having difficulty with walking and the stiffness. He has iced the area. He has been unable to run. He has also taken ibuprofen which helps with the pain. He did practice for soccer on Tuesday but was limited in some movements.  

PE: 
Full range of motion to the left patella.  No redness swelling or deformity present. Negative patella apprehension test. Negative anterior and posterior drawer test. Negative McMurray test
A and P:
Probable sprain/strain to his knee
Advised a Neoprene or Ace mobilizer for knee stability making sure it is form fitted.
Rest and take it easy and advised to sit out of the practice and playing soccer for the next 1 week.
Can take Advil bid or ibuprofen 400 mg for the next 2-3 days to help with the pain.
Gave him handout for knee exercises, advised doing the elastic band exercises for his knees. 
correct the errors, keep mostly the same, but keep it professional and also segregate CC, HPI, ROS, PE, and plan