CHART NOTE 1

Adam Carl

4/22/2016

SUBJECTIVE: Suture removal. Patient returns for removal of stitches placed about 7
days ago.
OBJECTIVE: Wound at lateral aspect of the left eye looks well healed. The 5-0 nylon
sutures were removed without difficulty.
ASSESSMENT: Laceration, healed.
PLAN: I advised him to use vitamin E for scar prophylaxis.
Peter DeLuca, M.D. /mj

CHART NOTE 2

Olson Reiss

7/5/2016

SUBJECTIVE: Olson came in for a suture removal from a left-knee wound. He is

doing well.
OBJECTIVE: Wound appears dry and clean; there are no signs of infection.
ASSESSMENT: Suture removal.
PLAN: All 5 sutures were removed. Bandage was applied.
Solomon Vineyard, M.D. /mj

CHART NOTE 3

Jason A. Others

3/2/2016

SUBJECTIVE: Michael comes in today for a 15-month examination. Mother has no

complaints. He is feeding himself and putting 2 words together when talking. For
motor and growth development, he is actually in the 22-month development.
Most recent hemoglobin was 12.3. His is above the 95 th percentile for height; 95th
percentile for weight.
OBJECTIVE: Head is normal. Ears are clear. Eyes are clear. Pupils are equal, round,
and reactive to light and accommodation. Throat is clear. Nose is clear. Neck has
good range of motion without nodes. Lungs are clear. Heart has a regular rate and
rhythm. Abdomen is soft without masses. Testicles are descended. Back is straight.
He is walking well. He has good muscle tone. See development forms in chart.
ASSESSMENT: Normal well-baby examination.
PLAN: Continue present diet and advance as tolerated. Immunizations were given;
see form. Recheck in 3 months, sooner if needed.
Douglas Michael, M.D. /mj

CHART NOTE 4

Emad Abdoul, 10 years old

1/4/99

CHIEF COMPLAINT: Sore throat, vomiting, and fever for 2 days.

VITAL SIGNS: Pulse, 120. Temperature, 102 orally. B/P, 90/50. Respirations, 40.
SKIN: Signs of mild dehydration present.
HEENT: Fundi, within normal limits. Eyes, normal. Ears, normal. Throat, red. Tonsils,
slightly enlarged.
NECK: No lymphadenophy.
RESPIRATORY SYSTEM: WNL.
CARDIOVASCULAR SYSTEM: WNL.
CNS: ENL.
SPINE: WNL.
IMPRESSION: URI and gastritis.
TREATMENT: Injectable penicillin G benzathine, IM. Childrens acetaminophen to be
taken every 4 to 6 hours. Patient to return in 3 days.
mj

CHART NOTE 5

William Tucker, Age 19

9/12/2016

CHIEF COMPLAINT: Cough, cold, and some difficulty in breathing for the past 48
hours. Some loss of appetite.
VITAL SIGNS: Plus, 120. Temperature, 100.1. B/P, 130/80. Respirations, 40.
GENERAL APPEARANCE: The patient was afebrile, active, and alert.
HEENT: Purulent discharge, both eyes. Conjunctive, red. Ears, normal.
LABORATORY EXAMINATION: Urinalysis, normal. WBC, unremarkable. Culture
from discharge from eyes showed cellular debris, gram-positive cocci identified as
staphylococcus aureus and staphylococcus epidermitis. Sweet chloride test, WNL.
X-RAYS: Chest, normal.
IMPRESSION: Chronic gastritis and conjunctivitis.
TREATMENT PRESCRIBED: Injection of 1,200,000 units of sterile penicillin G
benzathine. Occasional use of antacids recommended. Referred to ophthalmologist
(Berger) for treatment of conjunctivitis.
mj