Office Visit Note
Reason: Office Visit ElationNoteColOne: HPI: Hpi: 1. Menstrual symptoms * Menstrual cramps were absent this cycle. * Prior cycles have been painful enough that she has used ondansetron for menstrual symptoms. * She did not use ondansetron this cycle. Hpi: 2. Activity / weight-related habits * Has treadmills available at both parents’ homes but uses them only occasionally. Hpi: 3. Immunizations * She reported having received her second meningococcal vaccine. ElationNoteColOne: Reconciled Medications: Med: * Ondansetron (Zofran) PRN for menstrual symptoms ElationNoteColTwo: Data: Data: * Immunization record reviewed; second meningococcal vaccine was not documented in the chart. Data: * Discussed heart-rate targets for exercise, with goal range approximately 140-160 bpm and sustaining >30 minutes in that zone. ElationNoteColTwo: Vitals: Data: - BMI: 31.4 - Height (in): 63.7 - Temperature (°F): 97.3 - Weight (lbs): 181 ElationNoteColTwo: PE: PE: - General: Well appearing. NAD, Alert, well-appearing woman. Vital signs noted. - Eyes: Lids/conjunctivae normal. No discharge. PERRL, EOMI. - HENT: EACs no lesions. TM's clear. NOSE - Neck: Supple, no LAN, JVD, bruits, or thyromegaly. - Resp: No deformities. Clear to auscultation. - CVS: RRR w/o murmurs. Pulses symmetrical, regular. - Breast: no skin changes or abnl contour. No masses, LAN, no nipple discharge. - Abdom: Soft, normal BS, N/T, no HSM. - NS: Alert & oriented. Gait WNL. Strength and Sensation intact. DTR's symm, 2+. - Skin: No lesions, rashes noted. - Psych: Cooperative; appropriate affect. Affect appropriate, speech normal. - Rectal: defer ElationNoteColTwo: Assessment & Plan: Assessplan: 1. Weight management counseling [Z71.3] Assessplan: 2. Exercise counseling [Z71.82] Assessplan: 3. Dysmenorrhea [N94.6] Assessplan: 4. Immunization counseling [Z71.85] ElationNoteColTwo: Follow Up: Followup: Reassess progress in 3 months. Return sooner if school requires meningococcal vaccine documentation or if she wants to discuss GLP-1 therapy.