Subsequent Visit
Subjective
Patient is stable
no new complaints today
Past Medical History -reviewed
Past Surgical History - reviewed
Family History - reviewed
Social History - reviewed
Medication - Reviewed
Allergies - Reviewed
REVIEW OF SYSTEMS: All pertinent positives and negatives are stated in HPI and below, all other systems reviewed and are negative.
GENERAL: No malaise. No weight loss. No fever. No chills.
HEENT: No headache.
Eyes: No decreased vision.
Ears: No decreased hearing.
Nose: No bleeding.
Throat: No sore throat.
LUNGS: No shortness of breath. No cough. No COPD. No asthma.
CARDIAC: No chest pain. No palpitations. No orthopnea, no PND, no lower extremity edema.
GI: No Abdominal pain. No nausea. No vomiting. No constipation. No diarrhea. No change in weight. No change in appetite.
GU: No frequency. No hesitancy. No hematuria. No pyuria.
NEUROLOGIC: No dizziness. No neuropathy. No CVA. No headache.
MUSCULOSKELETAL: No neck pain or lower back pain.
Skin/Integuments - No breakdown
Physical Examination
Vitals: Reviewed
GENERAL APPEARANCE: Patient is alert, awake, resting, talking in complete sentences with no acute distress.
HEENT: No facial trauma or abnormalities. No tonsillar hypertrophy, no uvula deviation. No tongue swelling.
NECK: Supple, no lymphadenopathy. Trachea midline. No mass. No JVD
LUNGS: Clear to auscultation bilaterally. Normal breath sound. No Wheezing, rales or rhonchi.
HEART: Auscultation: RRR. Normal heart sound. No Gallop. No Murmur or rubs.
Palpation: Normal cap refill. Normal skin turgor. No JVD. No Pedal edema
ABDOMEN: Normal bowel sounds. Soft, non-tender, non-distended. No mass or hernia appreciated. No hepatosplenomegaly. No peritonitis
EXTREMITIES: Patient ambulatory. Good muscle tone. Moving all extremities equally. Good range of motion.
NEUROLOGIC: GCS 15. Patient is ambulatory with no gait abnormalities. Cranial 2-12 is grossly intact.
VASCULAR: Bilateral radial pulses, strong, equal.
SKIN: Pink, warm, dry. No pathological skin rash or lesion.
PSYCH: normal mentation, awake, alert, not suicidal, not homicidal.
Imaging Results:
I have personally reviewed the imaging results
Labs/path:
I have personally reviewed the lab results
Assessments and Plans: