DAX A&P Prompt Menu

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning. [Write a one-liner (<20 words) in telegraphic clinical language that states the reason for the visit, the key management decision and its main clinical rationale.] [Problem/Diagnosis Name] - [A very brief bullet point summarizing a key finding, action, or follow-up plan] - [Each point should be a separate bullet, written as a short clinical shorthand phrase] [Follow-Up: Brief description of follow up plan if discussed.] --- ## Conditional Boilerplate Text [Insert after the bulleted list when applicable.] If well child check or health maintenance discussed: "All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed." If any illness discussed: "Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan." If any injury discussed: "Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve." If ear infection discussed: "Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis." If strep test discussed: "Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management." If dehydration, vomiting, diarrhea, or decreased urination discussed: "Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids." If trouble breathing discussed: "Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission." If ADHD, weight, obesity, or strep throat discussed: "PCMH Reminder" --- ## Formatting Rules 1. Use a hyphen (-) for all bullets 2. Indent all bullets with 8 spaces 3. Write all bullet points in extremely brief, professional shorthand phrases 4. Keep bullets concise (ideally under 10 words per bullet) 5. Use standard medical abbreviations (RTC, PRN, BID, etc.) 6. If patient age is unknown, omit age from the one-liner 7. Only include one-liner and follow-up statement once. --- ## Few-Shot Examples 8yo with acute asthma exacerbation; starting ICS given persistent symptoms despite albuterol. Asthma - Flovent 44mcg 2 puff BID started - Continue albuterol PRN - Use spacer Follow-Up: Return to clinic in 3 months or as needed. --- 4yo WCC; normal growth/development, no concerns identified. Well Child Check - Growing and developing well - Reviewed anticipatory guidance All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Follow-Up: Return to clinic at next well child check or as needed. --- 2yo with vomiting and mild dehydration; giving Zofran and oral rehydration given tolerating small sips. Vomiting, mild dehydration - NDNT on exam with MMM - Zofran PRN, pedialyte, Tylenol, Motrin Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids. Follow-Up: Return to clinic as needed. --- 10yo with ADHD; switching from Concerta to Vyvanse given inadequate symptom control. ADHD - Concerta 27mg not effective - Transition to Vyvanse 20mg PO daily PCMH Reminder Follow-Up: Return to clinic in one month. --- Patient with likely viral URI; supportive care recommended, family declined COVID testing. Viral URI - Supportive care, fluids - Declined COVID test Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic as needed. --- 5yo with viral URI and acute otitis media; starting amoxicillin given bulging TM. Viral URI - Supportive care, fluids - Tylenol/Motrin PRN Acute Otitis Media - Right TM bulging, erythematous - Amoxicillin 400mg/5mL, 8mL PO BID x10d - Pain control with Tylenol/Motrin Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: RTC PRN --- 12yo with ankle sprain and pharyngitis; strep test pending, started supportive care. Ankle Sprain - Left lateral ankle tenderness, no instability - RICE protocol - Ibuprofen 400mg PO q6h PRN - Weight bearing as tolerated Pharyngitis - Rapid strep negative, throat culture pending - Symptomatic care with throat lozenges - Will call with results if positive Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. Follow-Up: RTC PRN or for strep results --- 3yo WCC with concurrent URI symptoms; addressed preventive care and acute illness. Well Child Check - Growing and developing well - Vaccines UTD - Reviewed anticipatory guidance Viral URI - Mild rhinorrhea, no fever - Supportive care, fluids - Tylenol/Motrin PRN All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: RTC next WCC or PRN ---

Reformat the assessment and plan into a structured, problem-oriented format. The output should be extremely concise for rapid scanning. [Problem/Diagnosis Name] - [A very brief bullet point summarizing a key finding, action, or follow-up plan] - [Each point should be a separate bullet, written as a short clinical shorthand phrase] [Follow-Up: Brief description of follow up plan if discussed.] --- ## Conditional Boilerplate Text [Insert after the bulleted list when applicable.] If well child check or health maintenance discussed: "All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed." If any illness discussed: "Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan." If any injury discussed: "Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve." If ear infection discussed: "Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis." If strep test discussed: "Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management." If dehydration, vomiting, diarrhea, or decreased urination discussed: "Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids." If trouble breathing discussed: "Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission." If ADHD, weight, obesity, or strep throat discussed: "PCMH Reminder" --- ## Formatting Rules 1. Use a hyphen (-) for all bullets 2. Indent all bullets with 8 spaces 3. Write all bullet points in extremely brief, professional shorthand phrases 4. Keep bullets concise (ideally under 10 words per bullet) 5. Use standard medical abbreviations (RTC, PRN, BID, etc.) 6. Only include the follow-up statement once. --- ## Few-Shot Examples Asthma - Flovent 44mcg 2 puff BID started - Continue albuterol PRN - Use spacer Follow-Up: Return to clinic in 3 months or as needed. --- Well Child Check - Growing and developing well - Reviewed anticipatory guidance All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Follow-Up: Return to clinic at next well child check or as needed. --- Vomiting, mild dehydration - NDNT on exam with MMM - Zofran PRN, pedialyte, Tylenol, Motrin Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids. Follow-Up: Return to clinic as needed. --- ADHD - Concerta 27mg not effective - Transition to Vyvanse 20mg PO daily PCMH Reminder Follow-Up: Return to clinic in one month. --- Viral URI - Supportive care, fluids - Declined COVID test Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic as needed. --- Viral URI - Supportive care, fluids - Tylenol/Motrin PRN Acute Otitis Media - Right TM bulging, erythematous - Amoxicillin 400mg/5mL, 8mL PO BID x10d - Pain control with Tylenol/Motrin Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: RTC PRN --- Ankle Sprain - Left lateral ankle tenderness, no instability - RICE protocol - Ibuprofen 400mg PO q6h PRN - Weight bearing as tolerated Pharyngitis - Rapid strep negative, throat culture pending - Symptomatic care with throat lozenges - Will call with results if positive Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. Follow-Up: RTC PRN or for strep results --- Well Child Check - Growing and developing well - Vaccines UTD - Reviewed anticipatory guidance Viral URI - Mild rhinorrhea, no fever - Supportive care, fluids - Tylenol/Motrin PRN All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: RTC next WCC or PRN

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write a single concise blurb in the style of a well-trained resident's oral presentation: state the key findings and clinical assessment, the treatment plan, and any forward-directed thinking such as return precautions, contingency plans, or follow-up expectations. The blurb may be one sentence or a few short sentences, but must remain as brief as possible without losing essential clinical meaning. [Problem/Diagnosis Name] [Resident-style blurb: assessment + plan + forward-directed thinking.] [Follow-Up: Brief description of follow-up plan if discussed.] --- ## Conditional Boilerplate Text [Insert after all problem blurbs and before the follow-up line when applicable.] If well child check or health maintenance discussed: "All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed." If any illness discussed: "Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan." If any injury discussed: "Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve." If ear infection discussed: "Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis." If strep test discussed: "Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management." If dehydration, vomiting, diarrhea, or decreased urination discussed: "Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids." If trouble breathing discussed: "Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission." If ADHD, weight, obesity, or strep throat discussed: "PCMH Reminder" --- ## Formatting Rules 1. Write the problem/diagnosis name followed by the blurb written below on a new line. 2. Write the blurb as flowing prose — no bullet points 3. Keep each blurb as concise as possible; length should match complexity of the problem 4. Use standard medical abbreviations (BID, etc.) 5. Include forward-directed thinking (return precautions, contingency plans, follow-up expectations) within the blurb itself where naturally applicable 6. Only include the follow-up statement once, at the end 7. If follow-up was not explicitly discussed, default to "Return to clinic as needed" --- ## Few-Shot Examples Asthma Persistent symptoms despite albuterol consistent with inadequately controlled asthma; starting Flovent 44mcg 2 puffs BID with spacer, continue albuterol as needed, and will reassess control at follow-up. Follow-Up: Return to clinic in 3 months or as needed. --- Well Child Check Healthy 4yo with normal growth, development, and exam; all anticipatory guidance reviewed, vaccines UTD, no concerns identified. All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Follow-Up: At next well child check or as needed. --- Vomiting, mild dehydration Tolerating small sips with moist mucous membranes and non-distended abdomen on exam, consistent with mild dehydration without need for IV fluids at this time; Zofran and oral rehydration with Pedialyte recommended, with Tylenol/Motrin as needed, and family instructed to go to ED if unable to maintain hydration. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids. Follow-Up: Return to clinic as needed. --- ADHD Inadequate symptom control on Concerta 27mg per parent and teacher report; transitioning to Vyvanse 20mg PO daily and will reassess response at one-month follow-up. PCMH Reminder Follow-Up: Return to clinic in one month or as needed. --- Viral URI Presentation consistent with viral upper respiratory infection; supportive care with fluids and OTC medications recommended, family declined COVID testing, return precautions reviewed. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic as needed. --- Viral URI Mild rhinorrhea without fever consistent with viral URI; supportive care with fluids and Tylenol/Motrin as needed, return precautions reviewed. Acute Otitis Media Right TM bulging and erythematous consistent with bacterial AOM; started amoxicillin 400mg/5mL 8mL PO BID x10d with Tylenol/Motrin for pain control, return precautions given for worsening or failure to improve. Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic as needed. --- Ankle Sprain Left lateral ankle with tenderness but no instability, consistent with mild sprain; RICE protocol initiated with ibuprofen 400mg PO q6h as needed, weight bearing as tolerated, return precautions given for increasing pain or swelling. Pharyngitis Rapid strep negative with throat culture pending; symptomatic care with lozenges and OTC analgesics for now, family to be contacted if culture returns positive to initiate antibiotics. Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. Follow-Up: Return to clinic as needed and pending strep culture results. --- Well Child Check Healthy 3yo with normal growth, development, and exam; vaccines UTD, anticipatory guidance reviewed, no acute concerns. Viral URI Mild rhinorrhea without fever consistent with viral URI; supportive care with fluids and Tylenol/Motrin as needed, return precautions reviewed. All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Next well child check or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write two concise prose statements: first, a brief clinical assessment capturing the key findings and your interpretation; second, a brief plan statement describing what is being done. Do not label these lines. Keep each statement as short as possible without losing essential clinical meaning. Do not use bullet points. [Problem/Diagnosis Name] [Assessment: key findings and clinical interpretation, unlabeled.] [Plan: what is being done, unlabeled. May include forward-directed thinking such as contingency plans or follow-up expectations where naturally applicable.] [Follow-Up: Brief description of follow-up plan if discussed.] --- ## Conditional Boilerplate Text [Insert after all problem blocks and before the follow-up line when applicable.] If well child check or health maintenance discussed: "All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed." If any illness discussed: "Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan." If any injury discussed: "Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve." If ear infection discussed: "Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis." If strep test discussed: "Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management." If dehydration, vomiting, diarrhea, or decreased urination discussed: "Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids." If trouble breathing discussed: "Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission." If ADHD, weight, obesity, or strep throat discussed: "PCMH Reminder" --- ## Formatting Rules 1. Write the problem/diagnosis name on its own line, followed by two unlabeled prose statements on separate lines 2. Assessment line first: key findings and clinical interpretation 3. Plan line second: management decisions and forward-directed thinking 4. No bullet points, no labels, no headers within the problem block 5. Keep each line as brief as possible; length should match complexity of the problem 6. Use standard medical abbreviations (BID, PRN, PO, etc.) 7. Only include the follow-up statement once, at the end 8. If follow-up was not explicitly discussed, default to "Return to clinic as needed" --- ## Few-Shot Examples Asthma Persistent symptoms despite albuterol consistent with inadequately controlled asthma. Starting Flovent 44mcg 2 puffs BID with spacer; continue albuterol PRN; will reassess control at follow-up. Follow-Up: Return to clinic in 3 months or as needed. --- Well Child Check Healthy 4yo with normal growth, development, and exam; no concerns identified. Anticipatory guidance reviewed, vaccines UTD, all parent questions addressed. All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Follow-Up: Return to clinic at next well child check or as needed. --- Vomiting, mild dehydration Tolerating small sips with moist mucous membranes and non-distended abdomen, consistent with mild dehydration without need for IV fluids at this time. Zofran and oral rehydration with Pedialyte recommended; Tylenol/Motrin PRN; family instructed to go to ED if unable to maintain hydration. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids. Follow-Up: Return to clinic as needed. --- ADHD Inadequate symptom control on Concerta 27mg per parent and teacher report. Transitioning to Vyvanse 20mg PO daily; will reassess response at one-month follow-up. PCMH Reminder Follow-Up: Return to clinic in one month or as needed. --- Viral URI Presentation consistent with viral upper respiratory infection; family declined COVID testing. Supportive care with fluids and OTC medications recommended; return precautions reviewed. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic as needed. --- Viral URI Mild rhinorrhea without fever consistent with viral URI. Supportive care with fluids and Tylenol/Motrin as needed. Acute Otitis Media Right TM bulging and erythematous consistent with bacterial AOM. Amoxicillin 400mg/5mL 8mL PO BID x10d started; Tylenol/Motrin for pain control; return precautions given for worsening or failure to improve. Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic as needed. --- Ankle Sprain Left lateral ankle with tenderness but no instability, consistent with mild lateral ankle sprain. RICE protocol initiated; ibuprofen 400mg PO q6h PRN; weight bearing as tolerated; return precautions given for increasing pain or swelling. Pharyngitis Rapid strep negative with throat culture pending; cannot exclude strep at this time. Symptomatic care with lozenges and OTC analgesics for now; family to be contacted if culture returns positive to initiate antibiotics. Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. Follow-Up: Return to clinic as needed and pending strep culture results. --- Well Child Check Healthy 3yo with normal growth, development, and exam; no acute concerns. Vaccines UTD; anticipatory guidance reviewed; all parent questions addressed. Viral URI Mild rhinorrhea without fever consistent with viral URI. Supportive care with fluids and Tylenol/Motrin as needed; return precautions reviewed. All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic at next well child check or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write one concise telegraphic prose statement capturing the key findings and clinical interpretation, then list the plan as brief bullet points beneath it. Keep the assessment statement as short as possible. Do not label either section. [Problem/Diagnosis Name] [Assessment: concise telegraphic prose, unlabeled.] - [Plan bullet: brief action, medication, or follow-up item] - [Additional plan bullets as needed] [Follow-Up: Brief description of follow-up plan if discussed.] --- ## Conditional Boilerplate Text [Insert after all problem blocks and before the follow-up line when applicable.] If well child check or health maintenance discussed: "All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed." If any illness discussed: "Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan." If any injury discussed: "Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve." If ear infection discussed: "Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis." If strep test discussed: "Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management." If dehydration, vomiting, diarrhea, or decreased urination discussed: "Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids." If trouble breathing discussed: "Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission." If ADHD, weight, obesity, or strep throat discussed: "PCMH Reminder" --- ## Formatting Rules 1. Write the problem/diagnosis name on its own line 2. Assessment: one unlabeled telegraphic prose sentence capturing key findings and clinical interpretation 3. Plan: unlabeled bullet points beneath the assessment, each a brief clinical shorthand phrase 4. Use a hyphen (-) for all bullets 5. Indent all bullets with 8 spaces 6. Keep bullets concise (ideally under 10 words per bullet) 7. Use standard medical abbreviations (BID, PRN, PO, RTC, etc.) 8. Only include the follow-up statement once, at the end 9. If follow-up was not explicitly discussed, default to "Return to clinic as needed" --- ## Few-Shot Examples Asthma Persistent symptoms despite albuterol consistent with inadequately controlled asthma. - Flovent 44mcg 2 puffs BID started - Continue albuterol PRN - Use spacer - Reassess control at follow-up Follow-Up: Return to clinic in 3 months or as needed. --- Well Child Check Healthy 4yo, normal growth, development, and exam; no concerns. - Vaccines UTD - Anticipatory guidance reviewed All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Follow-Up: Return to clinic at next well child check or as needed. --- Vomiting, mild dehydration Tolerating small sips, MMM, NDNT; consistent with mild dehydration, no IV fluids needed at this time. - Zofran PRN - Oral rehydration with Pedialyte - Tylenol/Motrin PRN - ED if unable to maintain hydration Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids. Follow-Up: Return to clinic as needed. --- ADHD Inadequate symptom control on Concerta 27mg per parent and teacher report. - Discontinue Concerta 27mg - Start Vyvanse 20mg PO daily - Reassess at one-month follow-up PCMH Reminder Follow-Up: Return to clinic in one month or as needed. --- Viral URI Consistent with viral URI; family declined COVID testing. - Supportive care, fluids - OTC medications PRN Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic as needed. --- Viral URI Mild rhinorrhea, no fever; consistent with viral URI. - Supportive care, fluids - Tylenol/Motrin PRN Acute Otitis Media Right TM bulging and erythematous; consistent with bacterial AOM. - Amoxicillin 400mg/5mL, 8mL PO BID x10d - Tylenol/Motrin for pain control Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic as needed. --- Ankle Sprain Left lateral ankle tender, no instability; consistent with mild lateral ankle sprain. - RICE protocol - Ibuprofen 400mg PO q6h PRN - Weight bearing as tolerated Pharyngitis Rapid strep negative, throat culture pending; cannot exclude strep at this time. - Symptomatic care with lozenges, OTC analgesics - Will call with results if culture positive to initiate antibiotics Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. Follow-Up: Return to clinic as needed and pending strep culture results. --- Well Child Check Healthy 3yo, normal growth, development, and exam; no acute concerns. - Vaccines UTD - Anticipatory guidance reviewed Viral URI Mild rhinorrhea, no fever; consistent with viral URI. - Supportive care, fluids - Tylenol/Motrin PRN All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic at next well child check or as needed.

Reformat the assessment and plan into a structured, problem-oriented format. For each problem, write one concise telegraphic prose assessment statement followed by bulleted plan items beneath it. Do not label either section. For known chronic or ongoing problems, the assessment statement must include: (1) the current status using trend language (improved, stable, worsening, or similar), and (2) the current medication and dose if applicable. For acute or new problems, write the same style of assessment statement but omit trend language and medication status — focus on key findings and clinical interpretation. [Problem/Diagnosis Name] [Assessment: telegraphic prose with trend language and current med/dose for chronic problems; key findings and interpretation for acute problems. Unlabeled.] - [Plan bullet: brief action, adjustment, or follow-up item] - [Additional plan bullets as needed] [Follow-Up: Brief description of follow-up plan if discussed.] --- ## Conditional Boilerplate Text [Insert after all problem blocks and before the follow-up line when applicable. Add a blank line before and after each boilerplate statement.] If well child check or health maintenance discussed: "All forms, labs, immunizations, and patient concerns reviewed and addressed appropriately. Screening questions, past medical history, past social history, medications, and growth chart reviewed. Age-appropriate anticipatory guidance reviewed and printed in AVS. Parent questions addressed." If any illness discussed: "Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan." If any injury discussed: "Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve." If ear infection discussed: "Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis." If strep test discussed: "Risk of untreated strep throat includes rheumatic fever and peritonsillar abscess. This problem is moderate risk due to pending lab results which may necessitate further pharmacologic management." If dehydration, vomiting, diarrhea, or decreased urination discussed: "Patient is at risk for dehydration, which would warrant emergency room care or admission for IV fluids." If trouble breathing discussed: "Patient is at risk for worsening respiratory distress and clinical deterioration, which would need emergency room care or hospital admission." If ADHD, weight, obesity, or strep throat discussed: "PCMH Reminder" --- ## Formatting Rules 1. Write the problem/diagnosis name on its own line 2. Assessment: one unlabeled telegraphic prose statement - For chronic/ongoing problems: include trend language and current medication/dose - For acute/new problems: include key findings and clinical interpretation; omit trend language and medication status 3. Plan: unlabeled bullet points beneath the assessment, each a brief clinical shorthand phrase 4. Use a hyphen (-) for all bullets 5. Indent all bullets with 8 spaces 6. Keep bullets concise (ideally under 10 words per bullet) 7. Use standard medical abbreviations (BID, PRN, PO, RTC, etc.) 8. Add a blank line between each problem block 9. Add a blank line between the last problem block and any boilerplate text 10. Add a blank line between each boilerplate statement 11. Add a blank line before the follow-up line 12. Only include the follow-up statement once, at the end 13. If follow-up was not explicitly discussed, default to "Return to clinic as needed" --- ## Few-Shot Examples Asthma Stable on Flovent 44mcg 2 puffs BID with spacer; albuterol use minimal. - Continue Flovent 44mcg 2 puffs BID - Continue albuterol PRN - Reassess control at next visit Follow-Up: Return to clinic in 3 months or as needed. --- Asthma Worsening; persistent symptoms despite Flovent 44mcg 2 puffs BID and albuterol PRN. - Step up to Flovent 110mcg 2 puffs BID - Continue albuterol PRN - Return sooner if symptoms not improving Follow-Up: Return to clinic in 6 weeks or as needed. --- ADHD Improved on Vyvanse 20mg PO daily per parent and teacher report; no side effects. - Continue Vyvanse 20mg PO daily - Reassess at next visit PCMH Reminder Follow-Up: Return to clinic in 3 months or as needed. --- ADHD Inadequate symptom control on Concerta 27mg PO daily per parent and teacher report. - Transition to Vyvanse 20mg PO daily - Reassess response at one-month follow-up PCMH Reminder Follow-Up: Return to clinic in one month or as needed. --- Obesity Stable; BMI unchanged since last visit, currently on dietary counseling and activity plan. - Continue dietary counseling - Encourage 60 min physical activity daily - Recheck BMI at next visit PCMH Reminder Follow-Up: Return to clinic in 3 months or as needed. --- Asthma Stable on Flovent 44mcg 2 puffs BID; albuterol use minimal. - Continue current regimen Viral URI Mild rhinorrhea, no fever; consistent with viral URI. - Supportive care, fluids - Tylenol/Motrin PRN Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic in 3 months or as needed. --- ADHD Stable on Vyvanse 30mg PO daily; parent reports good focus and behavior at school. - Continue Vyvanse 30mg PO daily Acute Otitis Media Right TM bulging and erythematous; consistent with bacterial AOM. - Amoxicillin 400mg/5mL, 8mL PO BID x10d - Tylenol/Motrin for pain control PCMH Reminder Risk of untreated otitis media includes persistent pain and fever, hearing loss, and mastoiditis. Recommended supportive care with OTC medications as needed. Return precautions given including increasing pain, worsening fever, dehydration, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with treatment plan. Follow-Up: Return to clinic in 3 months or as needed. --- Asthma Improved on Flovent 110mcg 2 puffs BID; symptoms well controlled, albuterol use rare. - Step down to Flovent 44mcg 2 puffs BID - Continue albuterol PRN - Reassess control at next visit Ankle Sprain Left lateral ankle tender, no instability; consistent with mild lateral ankle sprain. - RICE protocol - Ibuprofen 400mg PO q6h PRN - Weight bearing as tolerated Recommended supportive care with Tylenol, Motrin, rest, ice, compression, elevation, and gradual return to activity as appropriate. Return precautions given including increasing pain, swelling, or failure to improve. Follow-Up: Return to clinic in 3 months or as needed.