Subjective:
    - Chief Complaint:
    - History of Present Illness:
    - Past Medical History:
    (All this content is mapped to RFV)

Review of Systems:
    (This content is mapped to ROS)

Objective:
    (This content is mapped to PE)
Physical Exam:
    (If present, this content is also mapped to PE)

Assessment:
    (This content is part of AP)
Plan:
    (This content is also part of AP)

Office Visit - Complete

[Chief Complaint]

 - Capture the patient's main concern in their own words - Keep it brief and focused on the primary issue - Include duration if mentioned 

[History of Present Illness] 

- Provide a detailed narrative of current symptoms - Include onset, duration, location, characteristics - Document associated symptoms and modifying factors - Note impact on daily activities - Include relevant past medical history 

[Review of Systems]

 - Conduct a systematic review of body systems - Include both pertinent positives and negatives - Focus on systems related to chief complaint - Document: Constitutional, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Neurological, Skin 

[Physical Exam]

 - Document vital signs if mentioned - Include all examination findings - Note both normal and abnormal findings - Be specific about location and characteristics - Include relevant negative findings 

[Assessment]

 - Provide clinical assessment of the patient's condition - List differential diagnoses if appropriate - Include reasoning for primary diagnosis - Note any concerning findings 

[Plan]

 - List all treatment recommendations - Include medications with specific dosing - Document diagnostic tests ordered - Note referrals and consultations - Include follow-up instructions - Document patient education provided

Chief Complaint 

Persistent headaches for 3 weeks. History of Present Illness The patient reports experiencing daily headaches for the past 3 weeks. The headaches are described as bilateral, pressure-like pain primarily in the frontal and temporal regions. Pain intensity ranges from 4-7/10. Headaches typically worsen throughout the day and are aggravated by stress and computer work. Partially relieved by ibuprofen 400mg. Associated with mild photophobia but no nausea or visual changes. No history of similar headaches. Patient notes increased work stress recently. 

Review of Systems 

Constitutional: No fever, chills, or weight loss 
HEENT: Headaches as noted, mild photophobia, no vision changes, no nasal congestion 
Cardiovascular: No chest pain or palpitations 
Respiratory: No shortness of breath or cough 
Gastrointestinal: No nausea or vomiting 
Neurological: No focal weakness, numbness, or dizziness 
Musculoskeletal: Mild neck stiffness noted 
Physical Exam 
Vital signs: BP 128/82, HR 76, RR 14, Temp 98.4°F 
General: Alert and oriented, appears mildly uncomfortable HEENT: Pupils equal and reactive, no papilledema, mild tenderness over temporal regions Neck: Mild trapezius muscle tension, full range of motion Neurological: Cranial nerves II-XII intact, strength 5/5 throughout, reflexes 2+ and symmetric Assessment Tension-type headaches, likely related to stress and poor ergonomics. No red flags for secondary headache disorders. Differential includes migraine without aura, though pattern more consistent with tension-type. 

Plan 

1. Prescribed naproxen 500mg PO BID PRN for headache 
2. Recommend stress management techniques including regular breaks from computer work 
3. Ergonomic assessment of workstation 
4. Trial of progressive muscle relaxation exercises 
5. If no improvement in 2 weeks, consider prophylactic therapy 
6. Return in 4 weeks or sooner if worsening symptoms 
7. Educated on headache diary to track triggers

Focused Visit

[Chief Complaint] - State the primary reason for visit - Use patient's own words when possible [History of Present Illness] - Document relevant history for focused problem - Include symptom details and timeline - Note previous treatments tried - Include pertinent review of systems [Assessment] - Clinical assessment of the presenting problem - Include most likely diagnosis - Note any important differential considerations [Plan] - Treatment plan specific to the problem - Include medications and follow-up - Document any testing needed

Chief Complaint Sore throat for 2 days. History of Present Illness Patient presents with 2-day history of sore throat that began suddenly. Describes severe pain with swallowing, rated 8/10. Associated with fever to 101°F and fatigue. Denies cough, runny nose, or known sick contacts. Has been taking acetaminophen with minimal relief. No difficulty breathing or drooling. Assessment Acute pharyngitis, likely streptococcal given fever, absence of cough, and pharyngeal erythema with exudate. Rapid strep test positive. Plan 1. Amoxicillin 500mg PO BID x 10 days 2. Continue acetaminophen for fever and pain 3. Increase fluid intake 4. Return if not improved in 48-72 hours 5. Advised to avoid close contact with others for 24 hours after starting antibiotics

Quick Follow-up

[History of Present Illness] - Document interval history since last visit - Note response to treatment - Include any new or ongoing symptoms [Assessment] - Current status of condition - Note improvement or concerns - Update diagnosis if needed [Plan] - Continue or modify treatment - Schedule next follow-up - Address any new issues

History of Present Illness Patient returns for 1-week follow-up of acute sinusitis. Has completed 5 days of amoxicillin with significant improvement. Facial pressure and pain have resolved. Mild residual nasal congestion remains but improving daily. No fever since day 3 of antibiotics. Assessment Acute sinusitis, resolving with antibiotic therapy. Significant clinical improvement noted. Plan 1. Complete full 10-day course of amoxicillin 2. Continue saline nasal rinses 3. No additional medications needed 4. Return if symptoms recur 5. Preventive measures discussed including hand hygiene

{Office Visit}

[Chief Complaint] - Capture the patient's main concern in their own words - Keep it brief and focused on the primary issue [History of Present Illness] - Provide a detailed narrative of current symptoms - Include onset, duration, characteristics, and associated symptoms - Document alleviating or aggravating factors - Note impact on daily life [Review of Systems] - Conduct a systematic review of each body system - Include both pertinent positives and negatives - Cover: General, Skin, HEENT, Respiratory, Cardiovascular, Gastrointestinal, Musculoskeletal, Neurological [Physical Exam] - Document vital signs if mentioned - Include all examination findings - Note both normal and abnormal findings - Be specific about location and characteristics [Results/Data] - Include any lab results mentioned - Document imaging findings - Note any diagnostic test results [Procedure] - Document any procedures performed - Include technique and findings - Note patient tolerance [Plan] - List all treatment recommendations - Include medications with dosing - Document follow-up instructions - Note referrals if needed [Discussion/Summary] - Summarize key findings and decisions - Document patient education provided - Note any specific instructions or precautions

Chief Complaint Patient presents with persistent cough for 2 weeks. History of Present Illness The patient reports a dry, non-productive cough that began approximately 2 weeks ago. The cough is worse at night and with exertion. No associated fever, chest pain, or shortness of breath. Has tried over-the-counter cough medicine with minimal relief. No recent sick contacts or travel. Review of Systems General: No fever, chills, or weight loss HEENT: No sore throat, nasal congestion, or ear pain Respiratory: Persistent dry cough as noted in HPI, no dyspnea or wheezing Cardiovascular: No chest pain or palpitations Gastrointestinal: No nausea, vomiting, or reflux symptoms Musculoskeletal: No joint pain or swelling Neurological: No headaches or dizziness Physical Exam Vital signs: BP 120/80, HR 72, RR 16, Temp 98.6°F General: Alert and oriented, in no acute distress HEENT: Pharynx clear, no erythema or exudate Lungs: Clear to auscultation bilaterally, no wheezes or rales Heart: Regular rate and rhythm, no murmurs Results/Data No laboratory or imaging studies performed at this visit. Procedure No procedures performed. Plan 1. Likely post-viral cough syndrome 2. Prescribed dextromethorphan 30mg PO q6h PRN for cough 3. Recommend honey and warm liquids for symptom relief 4. Return if symptoms worsen or persist beyond 4 weeks 5. Consider chest X-ray if no improvement Discussion/Summary Discussed likely viral etiology of cough with expected resolution within 4-6 weeks. Patient educated on symptom management and warning signs to watch for. Agreed with conservative management plan.

{Progress Note}

[Chief Complaint] - Brief statement of the primary concern - Use patient's own words when possible [History of Present Illness] - Document progress since last visit - Note any changes in symptoms - Include response to current treatment - Document new concerns [Physical Exam] - Focus on relevant systems - Document changes from previous exam - Include vital signs if available [Plan] - Update treatment plan based on progress - Adjust medications as needed - Document next steps [Discussion/Summary] - Summarize overall progress - Note patient compliance - Document any barriers to treatment

Chief Complaint Follow-up for hypertension management. History of Present Illness Patient returns for 3-month follow-up of hypertension. Reports good compliance with lisinopril 10mg daily. Home blood pressure readings averaging 130/85. No side effects noted. Denies chest pain, shortness of breath, or edema. Has been adherent to low-sodium diet. Physical Exam Vital signs: BP 132/84, HR 68, RR 14 General: Well-appearing, no distress Cardiovascular: Regular rate and rhythm, no murmurs Lungs: Clear bilaterally Extremities: No edema Plan 1. Continue lisinopril 10mg daily 2. Continue dietary modifications 3. Recheck labs in 3 months (BMP, lipid panel) 4. Follow-up in 3 months Discussion/Summary Blood pressure improved but not at goal. Patient motivated to continue lifestyle modifications. Discussed importance of medication adherence and regular monitoring.

{Follow-up Visit}

[Chief Complaint] - State reason for follow-up - Note time since last visit [History of Present Illness] - Document interval history - Note treatment response - Include any new symptoms - Document medication compliance [Plan] - Continue or adjust current treatment - Order any needed tests - Schedule next appointment [Discussion/Summary] - Summarize visit and decisions - Document patient understanding - Note any concerns addressed

Chief Complaint 2-week follow-up for acute bronchitis. History of Present Illness Patient returns after completing 7-day course of azithromycin for acute bronchitis. Reports significant improvement in cough, now only occasional and non-productive. No fever, chest pain, or dyspnea. Completed full antibiotic course as prescribed. Plan 1. No additional medications needed 2. Continue supportive care 3. Return if symptoms recur or worsen 4. Annual flu vaccine recommended Discussion/Summary Acute bronchitis resolved with antibiotic treatment. Patient counseled on prevention strategies including hand hygiene and avoiding tobacco smoke exposure.