44 66 Office Visit Note Patient Name: Rodney Balbo DOB: 3/12/81 Rodney is an established patient with a history of hypertension, currently controlled with medication. He is here today to follow up due to a lingering headache he has had since he fell at home and hit his head. He was in the Emergency Room 2 days ago with a scalp laceration. His headache has gotten worse and now he feels drowsy. His wife mentioned that he was unconscious at the time of the fall, but they failed to mention that to the Emergency Room doctor. Assessment and Plan: Headache due to fall; drowsy. Call the outpatient imaging department to schedule an MRI of the brain for today. Total time spent with patient: 20 minutes Electronically Signed By: Rick Doe, MD 6/6/21 8:45am 31794171 (14 KB) DOWNLOAD
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