Follow up Visit Template

Subjective & Assessment

[For each medical problem, provide the following details in extremely concise list form. And have a corresponding Assessment under each problem if applicable following the format as below] 1. [Problem 1]: Subjective: - [Describe patient's subjective report related to this problem, including symptoms, changes, medication effects, and relevant history. Use bullet points.] Assessment: - [Diagnosis]. [Summarize clinical impression, response to treatment, or current status in an extremely concise way..] [If applicable & relevant, include Differential Diagnosis (DDx):] DDx: - [List possible alternative diagnoses with brief rationale or ruling out information.] 2. [Problem 2]: Subjective: - [Describe patient's subjective report related to this problem, including symptoms, changes, medication effects, and relevant history. Use bullet points.] Assessment: - [Diagnosis]:[Summarize clinical impression, response to treatment, or current status in a extreme concise way.] [If applicable & relevant, include Differential Diagnosis (DDx):] - [List possible alternative diagnoses with brief rationale or ruling out information.] Example: 1. Skin condition on legs: Subjective: - Browning due to venous incompetence. - Wears compression stockings Assessment: -Venous insufficiency: Leg skin browning due to venous incompetence; no ulcers or severe swelling. DDx: - Dermatitis: Consistent with venous stasis. 2. Recent ultrasound findings: Subjective - No abdominal aortic aneurysm. - Mild atherosclerosis in aorta. - Splenic calcifications, likely old infection; TB tests negative. - No active infection or TB symptoms. Assessment: -Granulomatous splenic calcifications: Likely old infection; TB ruled out. DDx: • Tuberculosis: Ruled out, no active infection.

Objective

[Present objective clinical data in an extremely concise format. Use list form without complete sentences. Include vital signs, physical exam findings, imaging, and lab results with values and brief interpretations. Use medical abbreviations and shorthand as appropriate.] For example: - BP 118/70 mmHg in office - Abd US: no aneurysm, mild atherosclerosis - Splenic calcifications; TB tests neg - Labs: Hgb 144, ferritin 78, cholesterol acceptable - PE not documented

Objective

[Present objective clinical data in an extremely concise format. Use list form without complete sentences. Include vital signs, physical exam findings, imaging, and lab results with values and brief interpretations. Use medical abbreviations and shorthand as appropriate.] For example: - BP 118/70 mmHg in office - Abd US: no aneurysm, mild atherosclerosis - Splenic calcifications; TB tests neg - Labs: Hgb 144, ferritin 78, cholesterol acceptable - PE not documented

Plan

[Summarize each problem’s management in a numbered list. Use brief phrases without full sentences. Include medication, lifestyle, follow-up, referrals, or tests as needed. Use medical abbreviations/shorthand as appropriate.] For example: 1. Overactive bladder:Continue Myrbetriq 50 mg daily. 2. Venous insufficiency:Continue compression stockings. 3. Granulomatous splenic calcifications:No treatment needed. 4. Mild atherosclerosis and hypertension: Maintain healthy lifestyle. Monitor cholesterol, BP. 5. Rectal and vaginal pruritus:Hydrocortisone Clotrimazole for vaginal.

Plan

[Summarize each problem’s management in a numbered list. Use brief phrases without full sentences. Include medication, lifestyle, follow-up, referrals, or tests as needed. Use medical abbreviations/shorthand as appropriate.] For example: 1. Overactive bladder:Continue Myrbetriq 50 mg daily. 2. Venous insufficiency:Continue compression stockings. 3. Granulomatous splenic calcifications:No treatment needed. 4. Mild atherosclerosis and hypertension: Maintain healthy lifestyle. Monitor cholesterol, BP. 5. Rectal and vaginal pruritus:Hydrocortisone Clotrimazole for vaginal.