Sample Progress Note
Sample Progress Note
Patient Name: Logan Clark
DOB: 01/15/2050
Date of Visit: 11/21/2070
Healthcare Provider: [Your Name]
S - Subjective:
The patient reports feeling “more fatigued than usual” over the past week, with an increase in headaches. Denies any recent changes in diet or sleep patterns. States, “I’ve been under more stress at work.” The patient also reports mild dizziness when standing up, but no chest pain or shortness of breath.
O - Objective:
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Vital Signs: BP 130/85 mmHg, HR 78 bpm, Temp 98.2°F
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Physical Exam: Mild tenderness in the occipital area, no swelling or redness.
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Neurological exam: Cranial nerves intact, no signs of vertigo, normal gait.
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Lab Results: Recent CBC within normal limits. No abnormalities were detected.
A - Assessment:
The patient is likely experiencing stress-induced tension headaches, exacerbated by workplace pressures. Mild dizziness may be related to stress or positional changes but does not indicate any immediate neurological concerns.
P - Plan:
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Continue stress management techniques (deep breathing exercises, mindfulness).
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Recommend over-the-counter ibuprofen for headache relief.
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Follow up in 1 week to assess progress.
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Schedule a follow-up if dizziness persists or worsens.
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Referral to a therapist for stress management if no improvement in 2 weeks.
