H and P

History and Physical Examination

Date of Evaluation:

Chief Complaint:

History of Present Illness:

The patient is a year-old patient who presents with

The location of the symptoms is

The duration of the symptoms is

The severity is

The associated symptoms include

Past Medical History

Social History - reviewed

Home Medication - Reviewed

Allergies - Reviewed

Review of Systems:

Head - no issue

Eyes - no issue

ENT - normal

Lungs - no short of breath

Cardiac - no chest pain

Abdomen -

Extremities - no issue

Skin/Integuments - normal

Vitals:

Reviewed

Physical Examination

Head - atraumtic

Eyes - PERL, no jaundice

ENT - normal

Lungs - clear to auscultation

Cardiac - RRR

Abdomen - soft, no peritonitis

Extremities - WNL

Skin/Integuments - WNL

Imaging:

I have personally reviewed the imaging studies

Labs:

I have personally reviewed the lab results

Assessments and Plans:

The patient is a

who presents with

The patient is stable.

All imaging studies and ancillary information have been reviewed

I have discussed with the patient the findings. I have also discussed with the

patient the recommended treatment including risks, benefits, and alternatives.

The patient agrees and would like to proceed with the proposed plan