Dr. Garcia
Physical Exam: Female
Appearance: This is a ?? whose apparent age is equivalent to chronological age, pleasant
and cooperative, in no acute distress.
Vital signs: Blood pressure ??, pulse ??, respiratory rate ??, temperature ??, height ??,
weight ?? pounds.
Eyes: PERRLA. EOMs intact. No conjunctival or lid lesions. Conjunctivae pink.
Ears, Nose, Mouth, Throat: No scars, lesions or masses. Tympanic membranes intact.
No nasal lesions. Gingivae pink. Tongue midline. No oral lesions. No erythema or
pharyngeal exudate.
Respiratory: Lungs clear bilaterally to auscultation. No wheezing, rales or rhonchi.
Respiratory effort symmetrical. No intercostal retractions or use of accessory muscles.
Cardiovascular: Regular rate and rhythm, S1-2. No murmur, gallop or rub. No clubbing
or cyanosis of nails. No edema in extremities. PMI nondisplaced.
Gastrointestinal: Abdomen soft, nontender. No rebound, no guarding, no
hepatosplenomegaly evidence. Bowel sounds are present in all quadrants. No herniation
is noted.
Rectal: Normal sphincter tone noted. No perirectal masses noted. Stool residue on
examining glove finger was heme negative.
Genitourinary: Bartholin’s/Skene’s/urethral glands within normal limits. Vulva/vagina –
no discharge or mucosal lesions. Cervix – no cervical motion tenderness, no discharge.
Adnexae – no palpable masses.
Musculoskeletal: No effusions. Full ROM without pain or contracture. Good muscle
strength and tone.
Skin: No acute rashes noted. No suspicious hyperpigmented lesions observed.
Neurological: Cranial nerves intact. Sensory intact throughout. No deficits noted.
Normal reflexes. Alert and oriented x 3.
Psychiatric: Oriented to time, place and person. Mood and affect good. No depression
or anxiety noted.
Hematologic/Lymphatic: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy is noted.
Garcia
Physical Exam - Male
Appearance: This is a ?? whose apparent age is equivalent to chronological age, pleasant
and cooperative, in no acute distress.
Vital signs: Blood pressure ??, pulse ??, respiratory rate ??, temperature ??, height ??,
weight ?? pounds.
Eyes: PERRLA. EOMs intact. No conjunctival or lid lesions. Conjunctivae pink.
Ears, Nose, Mouth, Throat: No scars, lesions, or masses. Tympanic membranes intact.
No nasal lesions. Gingivae pink. Tongue midline. No oral lesions. No erythema or
pharyngeal exudate.
Respiratory: Lungs clear bilaterally to auscultation. No wheezing, rales or rhonchi.
Respiratory effort symmetrical. No intercostal retractions or use of accessory muscles.
Cardiovascular: Regular rate and rhythm, S1-2. No murmur, gallop or rub. No clubbing
or cyanosis of nails. No edema in extremities. PMI nondisplaced.
Gastrointestinal: Abdomen soft, nontender. No rebound, no guarding, no
hepatosplenomegaly evidence. Bowel sounds are present in all quadrants. No herniation
is noted.
Rectal: Normal sphincter tone noted. No perirectal masses noted. Stool residue on
examining glove finger was heme negative.
Genitourinary: Penis present, no lesions. No testicular masses noted. Prostate is
nontender and flat.
Musculoskeletal: No effusions. Full ROM without pain or contracture. Good muscle
strength and tone.
Skin: No acute rashes noted. No suspicious hyperpigmented lesions observed.
Neurological: Cranial nerves intact. Sensory intact throughout. No deficits noted.
Normal reflexes. Alert and oriented x 3.
Psychiatric: Oriented to time, place and person. Mood and affect good. No depression
or anxiety noted.
Hematologic/Lymphatic: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy is noted.
Garcia
Review of Systems – Female
Constitutional: Denies unusual weight gain or loss, fever, chills or fatigue.
Eyes: Denies changes in, blurred or double, vision. No flashing or sensitivity to lights,
spots, or specks. Denies excessive tearing, redness or pain.
Ears, Nose, Mouth, Throat: Denies loss of hearing, ringing in the ears or earaches. No
discharge, itching, nasal stuffiness/sneezing. No difficulty swallowing or chewing,
change in voice or swelling in the neck.
Cardiac: Denies chest pain or angina, palpitations, skipped beats, dyspnea, orthopnea or
paroxysmal nocturnal dyspnea. No edema of feet, ankles or hands. No leg cramps or
intermittent claudication.
Respiratory: Denies cough or sputum production, hemoptysis, dyspnea, wheezing,
shortness of breath at rest or with exertion.
Gastrointestinal: Denies loss of appetite, heartburn or regurgitation. No nausea,
vomiting, vomiting of blood, constipation or diarrhea. No change in bowel habits, rectal
bleeding, blood in stools or abdominal pain. Denies food intolerance and jaundice.
Genitourinary: The patient denies bleeding between periods. No dysmenorrhea. Denies
discharges. No incontinence, frequency, burning, or painful urination.
Musculoskeletal: Denies joint pain, stiffness or swelling. No weakness of muscles or
joints. No limitation of motion or activity.
Integumentary: Denies rashes or itching, lumps, sores, dryness, changes in color or
moles.
Neurologic: Denies blackouts or fainting, weakness or paralysis, numbness or loss of
sensation or tingling of pins and needles. No tremors, convulsions or seizures,
lightheadedness or dizziness. No frequent or recurring headaches, head injury, balance or
speech problems, memory loss or confusion.
Psychiatric: Denies nervousness or anxiety, depression, change in moods or problems
sleeping.
Endocrine: Denies night sweats, excessive sweating, intolerance to heat or cold,
excessive thirst or hunger or polyuria.
Hematologic/Lymphatic: Patient denies being slow to heal after cuts, bleeding or
bruising easily, past transfusions or enlarged glands.
Garcia
Review of Systems – Male
Constitutional: Denies unusual weight gain or loss, fever, chills or fatigue.
Eyes: Denies changes in, blurred or double, vision. No flashing or sensitivity to lights,
spots, or specks. Denies excessive tearing, redness or pain.
Ears, Nose, Mouth, Throat: Denies loss of hearing, ringing in the ears or earaches. No
discharge, itching, nasal stuffiness/sneezing. No difficulty swallowing or chewing,
change in voice or swelling in the neck.
Cardiac: Denies chest pain or angina, palpitations, skipped beats, dyspnea, orthopnea or
paroxysmal nocturnal dyspnea. No edema of feet, ankles or hands. No leg cramps or
intermittent claudication.
Respiratory: Denies cough or sputum production, hemoptysis, dyspnea, wheezing,
shortness of breath at rest or with exertion.
Gastrointestinal: Denies loss of appetite, heartburn or regurgitation. No nausea,
vomiting, vomiting of blood, constipation or diarrhea. No change in bowel habits, rectal
bleeding, blood in stools or abdominal pain. Denies food intolerance and jaundice.
Genitourinary: Patient denies frequency or dysuria. Patient denies hematuria. Patient
denies change in force of stream when urinating. Patient denies incontinence or
dribbling.
Musculoskeletal: Denies joint pain, stiffness or swelling. No weakness of muscles or
joints. No limitation of motion or activity.
Integumentary: Denies rashes or itching, lumps, sores, dryness, changes in color or
moles.
Neurologic: Denies blackouts or fainting, weakness or paralysis, numbness or loss of
sensation or tingling of pins and needles. No tremors, convulsions or seizures,
lightheadedness or dizziness. No frequent or recurring headaches, head injury, balance or
speech problems, memory loss or confusion.
Psychiatric: Denies nervousness or anxiety, depression, change in moods or problems
sleeping.
Endocrine: Denies night sweats, excessive sweating, intolerance to heat or cold,
excessive thirst or hunger or polyuria.
Hematologic/Lymphatic: Patient denies being slow to heal after cuts, bleeding or
bruising easily, past transfusions or enlarged glands.