Sore throat
S:
Pt seen in office today complaining of sore throat that started 3 days ago. Pt describes pain as sharp, 6/10 on pain scale, localized to back of throat, and is worse with swallowing. Pt denies fever, ear/eye pain, rhinorrhea, N/V, bowel changes, recent travel, sick contacts, or other concerns at this time. No allergies.

O:
BP: 122/79
HR: 74bpm
BMI: 24.2
Temp: 37.5C
Constitutional: appears lethargic
HEENT: Erythema and edema of the tonsils and throat, with mild white exudate. Remainder WNL.
Cardiovascular: Normal rate/rhythm. No murmurs or rubs on auscultation. S1/2 present.
Respiratory: Clear bilaterally.
Skin: WNL.
Remainder of physical exam was unremarkable.
Vaccinations are up-to-date.
Rapid Strep A test – positive

A:
Streptococcal pharyngitis

P:
500mg Amoxicillin BID x 10d
Pt received a work note today to stay home for 2 days until antibiotics have started to take effect and pt is no longer contagious.
Pt to f/u PRN.

Yearly checkup
S:
Pt seen in the office today for her annual physical. Pt states she is adhering to her diet and walking 30mins 3x per week. Pt states she has seen a 10lbs weight loss over the last year and feels good about it. Pt denies other concerns at this time.

O:
BP: 122/79
HR: 74bpm
BMI: 34
Pt looks well.
Pt has visceral obesity, but otherwise physical exam was unremarkable.
Vaccinations are up-to-date.

A:
Class 1 obesity
Annual exam

P:
Rx Lipitor refill.
Routine CBC and CMP.
Pt to return 1 yr for next annual physical exam, or sooner PRN.

Broken wrist
S:
Pt seen in office today after falling onto L hand while playing pickleball yesterday, September 2, 2025. Pt went to ER 30mins later and had x-rays - which showed a fracture of the L scaphoid. Pt was put in cast and told to F/U with ortho in 6 weeks. Pt seen in the office today for work note, as pt's job is physically intensive.
Discussed limitations with pt and they agree with recommended time away from their physical job of 6w, at which time ortho will reassess.
Pt denies pain or other concerns at this time.

O:
BP: 122/79
HR: 74bpm
BMI: 29.2
Pt looks well, other than cast on L hand/wrist and minor abrasions on bilateral knees (clean and dry, with no evidence of infection).
Remainder of physical exam was unremarkable.
Tetanus is up-to-date; received Jan 2022

A:
L scaphoid fracture
Minor abrasions of knees bilat

P:
Pt received work note today to take time away until they can be reassessed for fracture
Pt to F/U with ortho in 6w
Will see pt after ortho appointment to determine if more time off of work is necessary or not

Docnote: Prescription renewal request sent to patient via Docnote. Service fee: $20.00. Request ID: a2b4c6d8-e0f2-4a6b-8c0d-2e4f6a8b0c2d.

Docnote: Document request sent to patient via Docnote. Service fee: $50.00. Request ID: f1e2d3c4-b5a6-7890-abcd-ef1234567890.

Docnote: Document attached to Insurance Form request via Docnote. Request ID: 8b3c7d2e-f1a0-4567-89ab-cdef01234567. Fulfillment complete.

Docnote: Missed appointment recorded and notification sent to patient via Docnote. Request ID: c3d4e5f6-a7b8-9012-cdef-3456789abcde.

Docnote: Professional time request sent to patient via Docnote. Service fee: $30.00. Request ID: d4e5f6a7-b8c9-0123-def0-456789abcdef.

Docnote: Provider's note sent to patient via Docnote. Service fee: $25.00. Request ID: 3e1ce4ce-23d2-8865-10a9-740786baad01.

Patient sent a request in Docnote today, asking for a refill of their Lipitor.
They were previously seen in office 3 months ago on Dec 1st, 2025. Physical exam and labs were unremarkable then.