Problem Solution Template - NEW (Dec 30)

Problem List

[Create a numbered list of clinical issues discussed. For each issue, provide a concise summary in the form of a list with dashes, including the history of illness, investigations done, objective evaluation, clinical assessment & plan.] Example: 1. Upper Respiratory Symptoms - Reports symptoms consistent with a viral illness. - Offered a prescription for a nasal spray to help clear congestion and relieve pressure. 2. Health Screening and Follow-up - Last blood work was over a year ago. -Previous results showed low B12 and a borderline glucose test. -Reports intermittent B12 supplementation. - Reports symptoms of brain fog and tingling in hands and feet, which can be associated with low B12. - Menstrual cycles are irregular, occurring every 3-4 months, which is a change from her usual pattern. - Denies a history of polycystic ovary syndrome. - Sleeps 4-7 hours per night and reports snoring. - Last Pap smear was in 2023, with a follow-up ultrasound scheduled for April due to a small cyst.

PLAN

- [List all the items included in the plan for the conditions discussed in the encounter. List medications or treatments prescribed, including dosage and purpose.] Example: - Tylenol prn - ICS nasal spray - RX given for post-viral cough and post-nasal drip - [List planned investigations, such as fasting insulin, lipids, HbA1c, or other lab tests.] - [Include follow-up plans for any previous abnormalities, such as self-test Pap smear in a specific year.]