Follow up note

Chief Complaint

[Anorexia, ADHD etc.]

History of Present Illness

[Patient Name] is on [Medication Name] [Dosage]. [He/She] has gained [Weight Gain]. [He/She] is drinking [Quantity] of boost daily. [No particular activity.] [[His/Her] focus is good and sleep is good.]

Past Medical History

Past Surgical History

Family History

Social History

The Review of Systems

Current Medications

[Medication Name] [Dosage] [Frequency] [Duration] [Refill Instructions]

Allergies

Vital Signs

Weight: [Weight] kg Height: [Height] cm BP: [BP] HR: [HR] bpm

Physical Examination

HEENT - [TM normal, neck supple, mmm, pharynx clear, no LAN] RESP - [clear bilat, no LAN, neck supple, mmm] CVS - [normal S1 and S2, no murmurs, good cap refill] ABD - [soft, non-tender, no hsm, no masses] MSK - [normal ROM, no joint swelling] CNS - [grossly normal] DERM - [no rash]

Test Results

Problem

Differential Diagnosis

Plan

[Patient Name] has [Duration] prescription of [Medication Name]. I am discharging from my practice.

Plan

[Patient Name] has [Duration] prescription of [Medication Name]. I am discharging from my practice.

Reason for follow up

Problem History: [Problem History]

Discussion

[Patient Name] is doing well with [Medication Name] [Dosage]. [We will continue with same dosage.] There is a lot of room to go up if required - up to [Max Dosage]. [[His/Her] weight I believe has room for catchup.] [The gain we have seen is catch up not growth at this age.] [[He/She] is turning [Age] soon and hence I will be discharging [him/her] from my practice.]

Impression & Plan

[Patient Name] has [Duration] prescription of [Medication Name]. I am discharging from my practise

Thank you note

Thank you for following this patient with us. We will keep you updated.