That's just the HPI box. You can do templates for every box Assessemnt box especially.
Just some examples:
Dx: CT Syndrome
# Carpal tunnel syndrome (G56.00): I explained the nature of this condition to the patient.
1. Start with avoiding offending actitivities at work or at play. Make note of ergonomic problems to fix. Consider an anti-inflammatory and ice/heat therapy.
2. Get a brace to wear, at least through the night, but consider during the day.
3. Next, consider injection therapy if not better in 3-6 weeks.
4. Finally, consider surgery if this is needed. We discussed the anatomy and what a surgical release would involve.
Dx: Hepatitis, transaminase elevated unkown cause
# HEPATITIS UNSPECIFIED:
I have discussed the most common causes of mild elevation in liver transaminase levels. The initial workup includes a variety of tests for possible causes.
1. Alcohol Related: patient does [not] drink excessive amounts
2. Hemochromatosis: may check iron, ferritin, and TIBC levels
3. Hepatitis B, C: may check viral hepatitis panel (HBsAg, Hep C ab)
4. DM: CMP, A1C, Lipid Profile, PT/INR
5. Medications: Tylenol, Herbs, others
6. NAFLD: evidence of metabolic syndrome,
Next visit: Obtain ultrasound or CT scan, or MRI
Recheck CBC, CMP, T-bili, Insulin Level
If Chronically Elevated of Fam Hx Cirrhosis:
Check for other Less Common Causes:
alpha-1-antitrypsin deficiency (may check level)
autoimmune hepatitis (ANA, Sm Muscle ab testing)
Wilson disease (cerum ceruloplasmin level)
Extra-Hepatic Causes:
Celiac Dz
Hemolysis (G6PD Def, Sickle Cell, Infect)
Muscular Disorders
Thyroid Disorders
Treat Underlying Disorders such as DM, Lipids, HTN, OSA and measure LFT q3-4 mo.
Initiate Lifestyle Changes
Metformin for DM
Pravachol or Lipitor for Lipids
Statin okay with increased LFT, recheck in 2 weeks and monthly x 3. Stop if LFT more than twice baseline.
If transaminases twice normal, then biopsy
AAFP 11/2011 7/2013
In One Year: If continues elevated, consider non-invasive fibrosis test and additional imaging. Refer if positive to GE
