1. Chief Complaint
name:
age:
sex:
race:
religion:
PCP:
unit#:
place of birth:
marital status:
date:
occupation:
2. Source
Patient.
3. History of Present Illness
4. Current Medications
5. Allergies
NKDA
6. Past Medical History
7. Family History
8. Social History
9. Review of Systems
General: Healthy. No significant weight or weight loss.
Skin: No rashes, moles, birthmarks, dryness, lumps, or pigment changes.
Hematologic: Denies anemia, easy bruising or bleeding, prior transfusions, pain,
fatigue, chills, and night sweats.
EENT: Denies eye pain or redness, cataracts, glaucoma, loss of visual fields, loss
of hearing, vertigo, sinusitis, postnasal drip, teeth or gum problems, oral cavity
ulcers or growths, sore throat, and hoarseness. No glasses.
Cardiorespiratory: Denies shortness of breath, coughing, sputum, coughing up
blood, trouble breathing, chest pain or pressure, wheezing, asthma, recurrent
bronchitis or pneumonia, palpitations, rheumatic fever, heart murmur, and
hypertension.
GI: Denies diarrhea, constipation, bloody, black, or tarry stools, hemorrhoids,
hepatitis, peptic ulcers, and abdominal pain.
Urinary: See HPI.
Genito-Reproductive:
Musculoskeletal: No pain, no arthritis.
Neurological: Denies dizziness, seizures, loss of sensation, weakness, and tremor.
Psychiatric: Denies depression, agitation, panic-anxiety, memory disturbance,
personality changes, and hallucinations.
10. Physical Exam
ED
Ht:
HR:
10C
Ht:
HR:
Wt:
BP:
HC:
Temp:
RR:
Wt:
BP:
HC:
Temp:
RR:
General Appearance: Alert and awake. Mildly frightened.
Skin: Somewhat dry. Normal texture. No abnormal lesions. Nails normal,
without clubbing, cyanosis, or deformities. Normal hair distribution.
Lymph Nodes: No axillary or inguinal node felt.
HEENT: Mild proptosis (R>L). Atraumatic, normocephalic. Lids without
swelling or lesions. Sclera white, conjuctiva pink. PERRL. EOMI. Visual fields
full to confrontation. No nose deformities. Frontal and maxillary sinuses nontender.
Neck: Supple, full range of motion. Trachea in midline. Thyroid not palpable.
Carotids +3 with brisk upstroke. No bruits. No palpable submental,
submaxillary, anterior or posterior cervical nodes. No supraclavicular nodes.
Lungs: Clear to percussion and auscultation bilaterally. Distant breath sounds.
Decreased flow.
Cardiovascular: RRR. Loud S2, normal S1. No S3, S4, rubs or murmurs. No
cyanosis, clubbing, or edema. Capillary refill within 2 seconds.
Pulses:
Carotid Brachial Radial Femoral Poplit. PT DT
R 3+
3+
3+
3+
3+ 3+
L 3+
3+
3+
3+
3+ 3+
Abdomen: Tender liver distally. Liver enlarged below costal margin laterally.
Abdomen not distended. Active bowel sounds.
Genitalia: Not attempted.
Rectal: Not attempted.
Back: No tenderness, symmetrical, and aligned.
Extremities: Full range of motion of joints.
Skeletal: No joint swelling, deformity, or tenderness.
Neuromuscular: Anxious about water dehydration test. Emotional when talking
about cancer family history and d/c abortions. Alert, oriented X3. Clear speech.
Cranial nerves II-XII intact by gross confrontation. No abnormal movements
seen.
Reflexes: Romberg negative.
Patellar, Achillies, biceps, triceps, brachioradialis, and
quadriceps reflexes all +2.
11. Laboratory Data
12. Problem List
Assessment
Plan
1)