DONNA SMITH - CHILD MACRO
REVIEW OF SYSTEMS: Information obtained from caregiver as noted. CONSTITUTIONAL:
No fever, no weight loss. HEAD: No evidence of trauma; no known headache. EYES: No
visual disturbances. EARS: No ear pain or drainage. NOSE: No bleeding, congestion, discharge
or pain. MOUTH: No known ulcers, pain, dental problems; no swelling of tongue, no difficulty
swallowing. NECK: There is no reported neck stiffness, no pain. CHEST: Denies problems; no
pain. HEART: No known palpitations or irregularity. LUNGS: No difficulty breathing, no
accessory muscle use, no cough, no congestion. ABDOMEN: No pain or distention. GI: No
nausea, vomiting, diarrhea or constipation. BACK: No evidence of injury or pain. GU: No
frequency, urgency, dysuria or hematuria. EXTREMITIES: No apparent complaints, no pain or
deformities. MOTOR: No apparent weakness. NEUROLOGICAL: No known weakness,
changes in attention, any paresthesia, etc.
PHYSICAL EXAM: VITAL SIGNS: Temperature , pulse , respirations , blood pressure .
GENERAL: The patient appears healthy, alert oriented and in no distress. HEENT: HEAD:
Normocephalic, no evidence of trauma. Fontanel normal. Eyes are reactive to light and
accommodation, extraocular movements are intact. Ears are patent, not injected. Nose is clear.
Throat is clear. Oropharynx is not injected, tongue and uvula are midline. NECK: Supple,
without lymphadenopathy or thyromegaly, no jugular venous distension or bruits. CHEST
WALL: Nontender, no scars. LUNGS: Clear to auscultation and percussion, no wheezes, rales
or rhonchi. HEART: Regular, without murmur or gallop, no thrills. ABDOMEN: Soft,
nontender, no localizing signs, no rebound or guarding, no hepatosplenomegaly, normoactive
bowel sounds. BACK: No localizing signs, no CVA pain, no vertebrae tenderness.
MUSCULOSKELETAL: Essentially normal, able to move extremities without difficulty. There
is no crepitation or deformity. Grips are equal, tone is symmetrical. NEUROLOGICAL EXAM:
Grossly unremarkable with no focal findings. Reflexes are equal. SKIN: No edema, ulcers,
lesions, cyanosis, clubbing or edema. PSYCHIATRIC: Grossly normal, no mental status
changes.
DONNA SMITH - ADULT MACRO
REVIEW OF SYSTEMS: GENERAL: The patient is not toxic or acutely ill-appearing. There is
no recent weight gain or loss. CONSTITUTIONAL: There are no fevers, chills, malaise or
fatigue. HEENT: There is no headache, blurred vision, double vision, eye drainage, ear
drainage or tinnitus. No runny nose or nose bleed. Mouth shows no sore throat, drooling,
inability to open the mouth adequately or dental pain. NECK: There is no stiffness, masses or
swelling. CHEST: There is no crepitus, no redness or point tenderness to palpation. LUNGS:
There is no cough, wheeze, denies shortness of breath with exertion or at rest. There is no
sputum production or stridor. HEART: There is no exertional chest pain, palpitations, orthopnea,
history of valvular heart disease, previous myocardial infarction or angina.
GASTROINTESTINAL: There is no abdominal distention, change in bowel pattern, diarrhea or
constipation, no hematemesis or hematochezia, no vomiting or fatty food intolerance.
GENITOURINARY: There are no urinary abnormalities, such as burning, stinging, frequency
passing small amounts of blood. There is no obvious blood in the urine, no blood in the stool.
There is no discharge. EXTREMITY EXAM: The patient denies joint pain, swelling or
erythema. There are no muscle cramps or spasms. No numbness or tingling to extremities or
digits. There is no limitation in range of motion to joints as compared to their normal.
NEUROLOGIC EXAM: There is no syncope, paralysis, paresthesia or seizure activity. There is
no altered level of consciousness, no confusion or disorientation or slurred speech. There is no
headache, dizziness, vertigo or memory impairment.
PHYSICAL EXAMINATION: GENERAL: The patient is alert, aware and oriented X3, no
acute distress. VITAL SIGNS: Stable. HEENT: Normocephalic, atraumatic and anicteric.
Pupils are equal, round and reactive to light and accommodation, extraocular movements are
intact. Fundi are unremarkable. Tympanic membranes are clear, canals without inflammation.
Pharynx without inflammation or exudates, uvula midline. Mucous membranes are moist,
without lesions, dentition is good. NECK: Supple, without jugular venous distension, bruits or
adenopathy, trachea is midline. CHEST: Clear to auscultation bilaterally, resonant to percussion.
HEART: Regular rate and rhythm, without murmurs, gallops, rubs, lifts or heaves. PMI is in the
5th interspace, midaxillary line. ABDOMEN: Soft and nontender, with normal bowel sounds, no
hepatosplenomegaly or bruits appreciated. There are no masses, no rebound or guarding, no
discoloration, no CVA tenderness. EXTREMITIES: Without cyanosis, clubbing or edema.
NEUROLOGICAL: Deep tendon reflexes are intact bilaterally, cranial nerves II-XII intact.
SMITH - Adult low back pain. 07/23/02
REVIEW OF SYSTEMS: SKIN: Denies rashes, lesions or urticaria. HEENT/SINUS:
No ear pain or drainage bilaterally. Denies sore throat or difficulty swallowing. No
tongue or throat swelling, denies hoarseness or change in voice. No maxillary or frontal
sinus pain bilaterally. Denies nasal congestion or drainage. No hearing loss or
changes. Denies photophobia, blurred vision or changes in vision, no eye pain,
pressure, itching or drainage. NECK: Denies neck pain, stiffness or swelling.
RESPIRATORY: No cough, shortness of breath, wheezing, stridor or hemoptysis.
Denies pain with deep inspiration. Denies sputum production, night sweats or pleuritic
pain. CARDIAC: Denies chest pain, pressure or tightness. No nocturnal dyspnea or
diaphoresis. Denies extremity swelling or edema. No palpitations, tachycardia, irregular
rhythm or cyanosis. GASTROINTESTINAL: No abdominal pain or cramping. Denies
nausea, vomiting, diarrhea or constipation. Appetite good and taking fluids well. Denies
blood in stool or black tarry stool. No unexplained weight loss or gain. Denies
abdominal distention, flatulence, jaundice or hematemesis. GENITOURINARY: Patient
denies urinary symptoms. No urinary incontinence, hesitance or retention. Denies
change in urinary pattern. No bilateral flank pain. MUSCULOSKELETAL: Denies joint
pain, swelling or erythema. No muscle cramps or spasms. No numbness or tingling to
extremities or digits. No limitation in range of motion to joints as compared to their
normal. NEUROLOGICAL: Patient denies headache, vertigo, dizziness or facial
weakness. No change in motor or sensory function. Denies paralysis, convulsions or
change in coordination. No difficulty with speech, slurred speech or aphasia.
HEMATOLOGIC: Denies any blood dyscrasia, easy bleeding or bruising. ENDOCRINE:
Patient denies goiter, exophthalmus, intolerance to heat or cold, dryness of hair or skin.
Denies polydipsia, polyphagia or polyuria.
PHYSICAL EXAM: GENERAL: The patient presents in no acute distress. The patient
is active and alert, does not appear acutely ill. VITAL SIGNS: Temperature , pulse ,
respirations , blood pressure . SKIN: No change in loss of hair or color changes in legs
or feet; temperature of skin is normal and symmetrical. No rashes or lesions, warm and
dry, turgor brisk without tenting. There is no erythema or warmth at site of the injury.
HEENT/SINUSES: HEENT/SINUSES: Normocephalic. No conjunctival injection, no
discharge. Tympanic membranes clear bilaterally without bulging or effusion. Bilateral
ear canals without inflammation or drainage. No nasal discharge or crusting. Pharynx
without erythema or exudate, uvula midline, mucous membranes moist, without lesions.
NECK: No cervical, occipital or submandibular nodes are palpated. Neck supple,
without meningeal signs. There is no reproduction of pain with application of slight
pressure to the top of the head. RESPIRATORY: Lungs are clear and equal bilaterally
without wheezes, rales or rhonchi. HEART: Regular rate and rhythm without obvious
murmur, rubs or gallops. There are positive femoral, popliteal and pedal pulses
bilaterally; peripheral pulses are 2+ and symmetrical throughout. ABDOMEN: Positive
bowel sounds, soft, nontender, no guarding, no rigidity, no rebound, no
hepatosplenomegaly, and no CVA tenderness bilaterally. GU: Sensation of perineum
intact therefore, cauda equina syndrome is absent. MUSCULOSKELETAL: Toe walk
unremarkable for calf muscles and S1 nerve root; heel walk unremarkable for ankle and
toe dorsiflexor muscles (L5 and some L4 nerve roots); positive straight leg raising of
side reproduces radicular pain when leg is raised between 30-60 degrees. Crossed leg
raise is negative bilaterally, foot inversion and eversion without difficulty or limitation.
NEUROLOGICAL: Deep tendon reflexes are 2+ and symmetrical; motor and sensory
are symmetrical; plantars downgoing, no ankle clonus bilaterally; muscle strength is 5/5
throughout; tandem gait within normal limits, no evidence of neurological deficits.
DONNA SMITH - ORTHO
REVIEW OF SYSTEMS: As noted above in the history of present illness, all other
systems reviewed and negative.
PHYSICAL EXAMINATION: PATIENT STATUS: _______ is awake, alert, cooperative,
in no distress, and well-hydrated. VITAL SIGNS: HEENT is normal. NECK: Supple,
without tenderness, decreased range of motion, meningeal signs or jugular venous
distention, lymphadenopathy or bruits. CHEST: Without tenderness to palpation,
retraction or accessory muscle use. LUNGS: Breath sounds equal bilaterally, without
rales, rhonchi or wheezes. HEART: Rate normal, rhythm regular, without ectopy or
murmur. ABDOMEN: Soft, without tenderness, guarding or rebound, bowel sounds are
normal, there are no palpable masses. NEUROLOGICAL: Cranial nerves II/XII are
intact, motor, sensory, cerebellar and reflexes are normal. SKIN: Normal, without
rashes or lesions. EXTREMITIES:
EMERGENCY ROOM COURSE: Post-splinting neurovascular exam is intact.