Muskuloskeletal endorses abdominal pain occasionally after throwing the football; denies any muscle or joint pain. Endocrine not assessed, hematopoietic denies easy bruising, physical Exam. Vital signs: Ht 510 Wt 160lbs hr 72 rr 16 bp 126/78 Temp Not measured. H is a depressed-appearing white male in no acute distress. Heent: Not examined, lymph nodes: Non-tender, no palpable masses. Neck: no masses, cardiovascular: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops Lungs: Lungs clear to auscultation bilaterally; no wheezes or crackles Abdominal: Abdomen soft and non-distended with no scars or striations no pulsatile masses, no abdominal bruits ascultated Spleen not.
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H does not have health insurance but is now covered by medicare. General As indicated in system the hpi, denies fevers or chills; endorses decreased appetite and a 5lb weight loss over the past 3-4 months; endorses fatigue. Heent: head denies headache, dizziness, syncope, ears denies difficulty or changes good in his hearing, denies tinnitis. Eyes denies problems or changes in his vision; denies blurred vision; denies seeing spots. Nose not assessed, throat complains of a lump in his throat; endorses dysphagia. Cardiovascular denies chest pain; denies palpitations. Pulmonary denies shortness of breath, denies cough. Gastrointestinal As indicated in the hpi, complains of sharp, epigastric abdominal pain; endorses constipation, denies diarrhea; endorses bloody stools. Genitourinary denies dysuria; denies increased frequency or urgency of urination. Neurologic denies numbness and tingling; denies paresthesias.
Prozac 20mg po qd; Started 6 months ago. Protonix discontinued 12-18 months ago, allergies: no known Drug Allergies, no food or insect allergies. Fh, mother died at age 74 of natural donation causes; mother had htn for many years. Fathers medical history not known, no known family history of colon cancer. H is a retired factory worker. He is divorced and has six children and one grandchild, whom he sees almost daily. H says he still often feels alone, isolated, and depressed. He denies past or present tobacco and illicit drug use. He denies alcohol use.
The blood is dark red in color and is not bright red. There is a sufficient amount of blood to turn the toilet water red. H does not know how many times per retrolisthesis week he experiences this bleeding. He has not seen a bloody bowel movement in the past week. Other active problems: Hypertension, diagnosed years ago, well-controlled with Metoprolol. Depression, poorly controlled; started Prozac 6 months ago but still feels depressed. Hospitalizations: mi, 2004, surgeries/procedures: Cardiac catheterization, post-mi, 2004, medications. Aspirin 81mg po qd since his mi 3 years ago. Metoprolol 100mg po qd for years.
H thinks the pain may at times be worse on laying down, and it does wake him up at night. H denies any abdominal trauma or injury. He endorses a 5lb weight loss over the past 3-4 months, decreased appetite, and fatigue. He has experienced some drenching night sweats, requiring him to change his shirt but not his sheets. He describes a lump in his throat with associated dysphagia. He has experienced some nausea with the abdominal pain but has not vomited. He endorses bloody stools with some bowel movements.
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The abdominal pain has been gradually worsening over the past 3-4 months. The pain has not changed or worsened essay acutely;. H seeks care for the pain at this time because he is now covered by medicare. The pain is located in the epigastric region and left upper quadrant of the abdomen. It does not radiate. The pain is relatively constant throughout the day and night but does vary in severity.
H rates the pain as 6/10 at its worst. H describes the pain as a sharp, burning pain. He has not tried taking any medicines to relieve the pain. The pain is not alleviated with rest. H thinks the pain may be aggravated by throwing the football, but he has also experienced the pain independent of playing football or exerting himself. The pain is not associated with food or eating, although. H does endorse occasional heartburn.
I sincerely value the product i am selling for Name of Company and enjoy my work. I will continue to do my best and am willing to listen to any suggestions you may have. I would welcome a meeting to discuss the situation and hope this issue can be resolved. Thank you for your attention to this matter. Sincerely, signature of Employee. Printed Name of Employee, list of enclosures: medical reports, by Andre Bradley.
Back to note guidelines, patient ID:. H, history and Physical conducted by:. History and Physical conducted on: October 1, 2007. Source: The patient gives his own history and appears to be a reliable source. Chief Complaint: Abdominal pain, history of Present Illness,. H is a 65 year old white male with a past medical history significant for an mi and depression who presents today complaining of sharp, epigastric abdominal pain of 3-4 months duration.
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I agree this is true, however, since i shortage was in the hospital for one month and recovering with physical therapy for the two following months during the last year, the reason my sales figures dropped is because i was able to work only nine months. I believe its only fair that this also be mentioned in my evaluation. I have enclosed a letter from my doctor and a copy of my hospital report. As it stands, the evaluation gives the impression that I didnt work as hard during the past 12 months, and this simply was not the case. If my sales figures are compared to nine months of the previous year, it will be clear that the numbers are higher this year. I am requesting that the reason my sales figures fell during the past 12 months also be included in my evaluation. If a new evaluation that fairly represents my efforts is not given, i respectfully request that this letter be attached to my official job appraisal.
Here is a sample rebuttal letter. It should be written in formal business-letter style and sent by certified mail, so the sender is sure resume the letter was received. It is recommended that the employee wait a day after drafting the letter before sending. This will give the employee an opportunity to make sure the letter does not have any incendiary language or put the recipient on the defensive. . Sample rebuttal Letter to your Employer. Employees Name, employees Address, city, state, zip Code, dATE. Employers Name, employers Address, city, state, zip Code, dear Employers Name, this letter is a formal response to the work performance evaluation you gave me on date. I appreciate that you recognized the energy and enthusiasm I have for my work and acknowledged my dedication to name of Company. You mentioned in my evaluation that my sales numbers have gone down in the last 12 months compared to the same time last year.
clearly presented and accurate. Acknowledge any positive comments mentioned in the evaluation. Not be accusatory or negative in tone. Mention any past or future positive interaction with the evaluator. Acknowledge suggestions given, have no grammar or spelling mistakes. Request that the rebuttal be attached to the original evaluation.
It will make the employee look like an inflexible and argumentative troublemaker. The first thing the employee should do is research the company procedures for disputing a performance appraisal or other accusation. If they cant find the policy, they can ask the human resources department for the proper steps for filing a rebuttal. Many companies and organizations have procedures that need to juan be followed in order for the rebuttal to be taken seriously. This may include a time frame for submitting a rebuttal and a list of people in the company or organization that should get a copy. If possible, the employee should get the rebuttal procedure in writing. . If the appraisal was a disciplinary action against the employee and he or she feels the action was discriminatory or that they were unfairly dismissed, they should check labor laws to see if the employer has acted illegally in the disciplinary action. The employee should gather documents that provide proof of their position such as previous positive performance appraisals, positive disciplinary statements, a list of successfully completed projects and any commendations.
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No one likes to address performance issues, but the sample write - ups included in 101 Sample, write, ups, for Documenting Employee performance Problems: a guide to progressive discipline And Termination make the process much easier. Expertly written, they communicate concisely, providing a chance to discuss and correct problems before they escalate. There are several reasons an employee may want to write a rebuttal letter to his or her employer. The most common reasons are for a poor performance rating, an accusation of metamorphosis a policy violation or wrongful discharge. When any of these things happen, the employee may feel angry and defensive. Before considering sending a letter, its important for the employee to gain control of his or her emotions, calm down and regain clear-headedness before writing a well-though-out letter that clearly explains their position. It is also important that the appraisal or disciplinary action be unfair. If the negative job appraisal is true, such as the employees sales figures have fallen in the past 12 months, or the employee has systematically broken office rules, there is no point in sending a rebuttal letter.