PATIENT:
MRN:
CC:
HPI:
ROS:
Constitutional: denies fevers, chills, night sweats, change in appetite, change in weight
ENT/Eyes: denies vision or hearing changes, nose bleeds
Cardiovascular: denies chest pain, chest pressure, palpitations, diaphoresis, ankle edema, orthopnea, PND
Pulmonary: denies SOB, cough, hemoptysis, wheeze
GI: denies diarrhea, nausea, vomiting, dysphagia, heartburn, BRBPR, melena
GU: denies urinary frequency, urgency, dysuria, hematuria, vaginal/penile discharge
MSK: denies arthralgias, arthritis, stiffness, recent trauma
Neuro: denies headache, lightheadedness, vertigo, weakenss, numbness, paresthesias, seizures, gait changes
Skin: denies rashes, masses
Endo: denies heat/cold intolerance
Exposures: denies sick contacts, international travel, insect bites, animal exposures
Psych: denies depression, anxiety, insomnia, mood disturbances.
MEDICAL HISTORY:
SURGICAL HISTORY:
FAMILY HISTORY:
- CVS
SOCIAL HISTORY:
Lives ____________________ with ______________. Works as ________________. Eats healthy diet and exercises regulary.
ALLERGIES:
VITALS: T HR BP RR O2 sat %
GEN’L NAD; Non-toxic appearing.
HEENT MMM; No scleral icterus; No pale conjunctiva
NECK Supple; No thyromegaly; No LAD. JVP<5 cm; No carotid bruits
CV: RRR; normal S1, S2 no c/r/m/g; Pulses 2+ bilaterally DP/PT/Radial
LUNG: CTA bilaterally with no c/r/w; no increased work of breathing
ABD: Soft, non-tender, non-distended; NABS. No HSM. No masses, rebound. No CVA tenderness.
EXT: Warm well-perfused with cap refill < 2 sec; No clubbing/cyanosis/edema
NEURO: AO x 3; CN II-XII grossly intact including PERRL, EOM, & visual fields; Motor: 5/5 B UE/LE; sensation grossly intact to light touch; DTRs (biceps/triceps/brachioradialis/patellar/Achilles) 2+ & symmetric bilaterally; RAM intact; Good coordination on Finger-to-nose/heel-to-shin; no pronator drift
SKIN No rashes
WOUND: Dressing C/D/I; No drainage/erythema/edema
RECTAL: Good sphincter tone; Stool guaiac neg
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Ithan Peltan, MD