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Pt. ℅ sharp pain in LUQ, pain began 3 days ago and is consistent. Pt. explains that he has h/o heart pain since he was 20 y/o. Pt. has no accompanying symptoms. Pt. had tried taking 600mg of Tylenol every 4 hours since pain began, Tylenol has not provided relief.

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Pt referred to a cardiologist for ECG interpretation and further DX.

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05/30/2024 6:30 pm

Patient ℅ HA constantly

No Abx administered

05/30/2024 6:49 pm

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Pt. c/o of fishy odor x5 days along with dysuria. She states discharge has changed in consistency and color. Pt. reports history of bacterial vaginosis. denies itchiness. Pt. is not currently taking any medication.

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Called pt at 10am to reschedule F/U appointment for T&A. No answer received. AS,MA

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Pt called office inquiring on side effects of the ABX he was prescribes as he is experiencing  SOB & HA.

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H/O of Dermatitis. Applied topical hydrocortisone cream. Pt education on proper skin care and f/u on tx given.

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.On 05/30/2024, 5:00pm . Call patient to remind CXR and BX . B need to be done a week before next visit. MA, PN

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Pt is prescribed levothyroxine for hypothyroidism treatment. Pt instructed to take 75 mg 30 minutes a.c. QAM.

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Pt given instructions to come in on Tuesday for CXR and to check ROM for R arm.

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1. Pt. has a H/O of bronchitis and is taking Abx for it.

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5/30/2024 6:00 PM

Reported SUD post T&A

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Pt came in to clinic for F/U appt, stating she is having contractions. Pt EDD is 07/11/2024.

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EDD calculated to be 09/01/2024. Fetal heart rate WNL. Routine CBC drawn.

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Called and left PT a VM confirming her appt tomorrow at 3pm. PT expressed understanding.