Keeping Your GP Consultations

Under 10 Minutes

Progress notes Tuesday February 13 2018 16:34 Case 3
Dr Zen

Saw chiropractor yest

Having problems with back: Long term/recurrent

Due to slight scoliosis, MVA at 17yo

Rx: Click acupuncture to neck + back

Chiropractor also cracked back

evened hips : R higher than L

Wants pill script
last pap 6 yrs: one abnormal

last ok

nil Pap since 6 yrs ago: remind needs Pap

NOW
Nausea

like want to vomit

headache

Chiropractors told her nervous system in shock

reacting in a good way

Body has never been this good before

Body needs to get used to it: being good

Examination:

shoulder blades ok : level
sl asymmetry with bend over

neck discomf from yest

used to be a power lifter

if lifts : heavy weight : pinches L infrascapular

Suggested need to see X-rays(had some previously) and

should not do further manipulation treatments> getting unhappy

I’m actually here for my throat

Examination:

Actions:

Prescription added:

CECLOR CD SR TABLET 375mg 1 b.d.

Prescriptions printed:

CECLOR CD SR TABLET 375mg 1 b.d.

General:
BP (Sitting): 118/90

Pulse (Sitting): 89 Irregular

Prescriptions printed:

LEVLEN ED TABLET 150mcg/30mcg (21), Inactive (7) 1 daily

Unhappy re any suggestion that chiropractic Rx should slow/stop

Crying upset at front reception.