I got the idea cause people said my notes were too pedantic. Well screw them they're all gonna look like this from now on:
Subjective:
Patient 6 months throat problem. Saliva low. Mouth dry. Swallowing hard. Food and water stick. Feel ball in throat like blow up. Throat feel close. No breathe good sometimes. Chest wheeze long time but this new. Acid reflux bad 1-2 year. Night time burning in throat and belly. Pain bad. Stress high. Weight go up.
- Past Medical History: Severe asthma. Bleeding ulcers. Stress and depression.
- Medication History: Omeprazole twice day.
- Social History: Smoke cigarettes long ago. Stop 10 year. Chew tobacco long time. No heavy drink. Stress from kids.
Objective:
No increased work of breathing.
No obvious skin lesions.
Mentally alert with normal mental status and nonfocal motor examination.
No scary thing on camera. No cancer. No infection. ongue big.
Assessment/Plan:
- Laryngopharyngeal Reflux (LPR): Acid leave food pipe and go to throat. Make throat swell and hurt. Swallow hard.
- Plan: Small dinner. No fat oil food at night. Big breakfast and lunch. Try skip dinner. Referral to stomach doctor for camera in food pipe. Try lose weight. Return 3 month.