Name:
Age:
Sex:
Chief Complaint:
SUBJECTIVE
Pt is a *** y/o *** *** with a history of recent *** who presents with ***. Onset was
***, during ***. Pain is ***, localized to ***, radiates to ***, rated as ***/10. Sx/Sx
are made worse by ***. Sx/Sx are made better by ***. Pt has/not experienced similar
Sx/Sx in the past and it was 2/2 ***. Onset of Sx/Sx was associated with ***. There
was no ***.
PAST MEDICAL HISTORY: ***
PAST HOSPITALIZATIONS: ***
PAST SURGICAL HISTORY: ***
IMMUNIZATIONS: Up to date.
SOCIAL HISTORY: ***
FAMILY HISTORY: ***
HOME MEDICATIONS: ***
ALLERGIES: ***
REVIEW OF SYSTEMS: -fevers, -chills, -night sweats, -fatigue, -changes in weight, vision changes, -ear pain, -nasal congestion, -sore throat, -cough, -CP, -palpitations, DIB, -hemoptysis, -abd pain, -changes in appetite, -hematemesis, -hematochezia, N/V/D, -urinary frequency/urgency/retention, -dysuria, -hematuria, -incontinence, myalgia, -arthralgia, -rash, -bruising, -HA, -dizziness, -syncope, -SI/HI, -hallucination,
-depression, -anxiety, -heat/cold intolerance, -polydypsia, -polyphagia, -polyuria, excessive bruising/bleeding.
OBJECTIVE
VS: ***/***, HR: ***, RR: ***, T ***° C, ht *** cm, wt *** kg, BMI
General: Pt is a *** y/o white *** WNWD NAD. Pt is alert and cooperative.
Skin: Warm, dry, normal color. No rashes, cyanosis, peripheral cyanosis.
HEENT: Head normocephalic, atraumatic. No sclerae icterus.
Heart: RRR S1 S2 without clicks, rubs, gallops.
Lungs: CTA bilat. Work of breathing is normal and unlabored.
Abd: Soft, flat, nontender, nondistended without masses or organomegaly. Bowel
sounds active x4.
Extremities: Pt moves all extremities equally and with ease. Pulses 2+ bilaterally. No
pedal edema.
Neuro: CN II - XII grossly intact. Gait is normal.
ASSESSMENT and PLAN
1. ***
Kaitlyn Parker, PA-Student
Wednesday, September 4, 2019 7:50:32 AM