Sample New patient Note

CC: 32 y.o. F referred from the ER after 3 visits for nausea and vomiting. She is here to follow up on the results of an abdominal ultrasound.

HPI: Patient is a 32 y.o. female, G2P2. She describes no significant past medical history. However ever since the age of 5, she has experience nausea, vomiting every 3 months. During her pregnancies in the past, she has also experience severe vomiting. This resulted in her only admission to CPMC with hyperemesis gravidum, she had an EGD on the admission which was notable only for mild esophagitis.

Patient has been at baseline health, and works as a office cleaner. She has not regular medical follow up, in the past 3 years, she has presented to the ER with 3 episodes of nausea and vomiting. Each time she was treated hydration. On one of the admission she reported headache, and had an LP. An MRI was done on follow up, which was normal, it was only notable for cervical disc bulge.

Patient describes these episodes to occur nearly once to three times, every three months. It usually start with an unilateral headache, rated 8/10, nausea and vomiting then follows. The episode would last for at least 6 hrs, at which time she is usually quite debilitated. The headache is severe, pounding, and can be triggered by rain, change in sleep schedule, stress, and menses. During the headache she has photophobia, phonophobia, and sensitivity to strong smells. There is no visual changes proceeding the headache, although she is usually able to predict an onset of the attack based on her mood on that day. She has never experienced any neurological symptoms during headaches. She takes acetaminophen 325mg per headache and N/V attack, sometimes it helps

ROS: excellent baseline exercise tolerance, walks 20 blocks to work daily. No sob, cp, fatigue with walking. Appetite great, bowels normal, no BRBPR, no melena, she has never had hematemesis or hemoptysis. She has not had any cough, or recent URI symptoms. The rest of the review of system is normal, including normal vision, normal menstrual cycle, and no psychiatric symptoms.

Meds: Tylenol prn Allergies:NKDA

Soc hx: lives with husband and 2 children age 6 and 3, both girls. Immigrated from Kosova 8yrs ago, where she worked as a math teacher. She is trying to her parents to come to the U.S. She denies toxic chemical exposure, did not experience the war first hand. She denies alcohol, drugs. At times smokes twice a month, only after dinner. She denied STDs and was tested for HIV on her last pregnancy.

PsurgHx: none, both delivery NSVD

Family Hx: Mom with also "cyclical vomiting", otherwise no diabetes, breast/prostate/colon Ca, early MI, CVA

Exam: Well appearing

VS BP 120/80 P 72 R 16 Afebrile BMI 22

HEENT:NCAT, disc sharp, vessels wnl, EOMI, PERRL, pharynx clear, TM wnl

Neck: no JVD, LAN, thyromegaly, neck good ROM

Cor: RRR S1, S2 no m/g/r

Lungs: clear Back: no scoliosis, non tender

Abd: +BS, soft nontender to deep pal

Extrem: no edema, 2+ pulses, joints wnl

Neuro: nl CN, nl gait, tandem, walks on heels and toes, negative Romberg, reflexes 2+ through out, intact RAM and finger to nose, strength 5/5 through out. Sensory exam with intact distal sensation to pain, propioception, and vibration.

GYN:deferred, patient had PAP 2 months ago

Labs: Usg on last ER visit: nl reading, ER labs notable for nl Hct, WBC, BUN/Cr, electrolytes, LFT, amylase/lipase, choleseterol

Impression: 32y.o. F with no past medical history aside from recurrent nausea and vomiting, presenting for evaluation. Exam and labs are normal.

1. N/V/HA: The description of N/V in combination with headache makes one suspect migraine without aura. The long history of this condition makes intracranial lesions less likely, however patient already has a negative MRI. Many features, including the N/V/headache triggers are classic for migraine. Given the infrequent nature but the severity of the events (drives her to go to the ER) would opt for triptan therapy, for now would not start prophylactic treatment of migraine. She reports she would be able to obtain insurance coverage for the pills, as it is very expensive. Patient is instructed on the use, and possible side effects of triptans. A Rx of rizaptriptan 10mg #6 tabs will be given. Patient is instructed to avoid headache triggers, and try to keep a regularity in her life.
2. Health Maintenance: last PAP 8 months ago, last Td booster >15 yrs, PPD negative 1yr ago for work clearance, cholesterol was checked on one ER visit, it was normal. Patient is advised to have Td booster shot. Counseling provided on nutrition, smoking cessation, safety, and exercise.
3. Return to clinic in 3-6mo, earlier if medications not helpful.

HM Hep B and Td vaccination in 2001, Pap with outside GYN this yr