Example_2_-_TB_Chart_Progress_Note.pdf
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- Attached to
- Electronic Health Records
- Solicitation number
- 2024-280
- Issued by
- Collin County, Texas
About this file
This document is a medical progress note for a patient with pulmonary tuberculosis, created on September 28, 2018, by Dr. Arifa Nishat for patient Liz Lemon (Patient ID: 1007). The progress note details a follow-up appointment for tuberculosis, with the patient reporting weight gain but denying other systemic symptoms across constitutional, eye, cardiovascular, respiratory, and gastrointestinal systems.
The medical documentation includes specific diagnostic orders for the patient: a chest X-ray (frontal and lateral/apical lordotic), a comprehensive metabolic panel (CMP), a human chorionic gonadotropin (HCG) measurement, and a complete blood count with platelets and differential. The patient's assessment confirms pulmonary tuberculosis (coded as 011.90/A15.0), and the disposition instructs the patient to call or return if symptoms worsen or persist. The note was electronically signed by the physician and printed on November 1, 2024.
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Text version
Progress Note
Chie f Compla in t l Follow up
His tory Of Present I l lness
Rev iew o f Sys tems
¡ Admits : weight gain ¡ Denies : fatigue, fever, malaise, night sweats, weight loss, loss of appetite
¡ Denies : eye discomfort, eye pain, impaired vision
¡ Denies : chest pain
¡ Denies : shortness of breath, cough, productive cough
¡ Denies : nausea, vomiting, diarrhea, constipation, loss of appetite, abdominal pain
Assessment l Tuberculosis, Pulmonary 011.90/A15.0
Plan
¡ Chest X-ray, frontal and lateral/apical lordotic (71021) - - 09/28/2018 ¡ CMP (comprehensive metabolic panel) (80053) - - 09/28/2018 ¡ HCG (human chorionic gonadotropin) measurement (84703) - - 09/28/2018 ¡ CBC + platelets + diff auto (85025) - - 09/28/2018
¡ Call or Return if symptoms worsen or persist.
Electronically Signed by: Arifa Nishat, MD -Author on September 28, 2018 01:51:42 PM
Patient Name: Liz Lemon
Patient ID: 1007
Sex: Female
Birthdate: January 11, 1969
Create Date: September 28, 2018
Constitutional
Eyes
Cardiovascular
Respiratory
Gastrointestinal
Orders
Disposition
Pt here for pulmonary TB follow up doing well.Denies any problems
[Date Printed:11/1/2024] Page 1 of 1[Progress Note] [Liz Lemon] [1007]
[Digital Signature Validated]
File details come from the government source that posted it. Updated .