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Sample Report

Sample Report

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Published by api-3833013

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Published by: api-3833013 on Oct 18, 2008
Copyright:Attribution Non-commercial

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03/18/2014

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physical examination
vital signs: pulse 102, respiratory rate 22, temperature 96.5 f, blood pressure
\ufffd

154/64, pulse oximetry 98% on room air.
general examination: sitting quietly on the cart, alert, awake, and appropriate.
skin examination: skin examination showed no petechiae, no abnormal bruising
except for a quarter-to-silver-dollar-size bruise in the right upper chest wall
region that was somewhat yellowish. no other rash.
neck: neck was supple. no jvd or adenopathy appreciated. no axillary or inguinal
adenopathy appreciated.
oropharyngeal examination: clear. had normal mucous membranes and no mucus icteric
changes.
eyes: eyes were normal without icteric changes.
extremities: extremities all appeared atraumatic, showed full range of motion. no
abnormal swelling or joint pain or tenderness.
chest: clear to auscultation.
cardiac: regular rate and rhythm without murmurs, rubs, or gallops.
abdomen: soft and nontender. no hepatosplenomegaly appreciated.
neurological examination: moving all four extremities nonfocally with good
strength.
mental status examination: awake and oriented with normal mood and affect.

sample medical report

diagnoses
1. cerebrovascular accident.
2. schizophrenia.
3. recurrent transient ischemic attacks.

procedures
1. echocardiogram.
2. holter monitor.

history of present illness
this is a 46-year-old right-handed woman with a history of hypertension,
schizophrenia, and an ovarian tumor resected surgically and with radiotherapy
treatment. she presented to the emergency room with a 4-hour history of difficulty
talking, along with numbness and weakness on the right side. she was in her usual
state of health until early the morning of admission when she woke up and noted
numbness on her right side. her numbness was associated with weakness as well as
difficulty speaking, with no associated headache, chest pain, fever, chills,
double vision, difficulty swallowing or palpitations. she reported having a
similar incident about one month prior to admission when she was seen in the
emergency room, but at that time her symptoms resolved while in the er. ct scan at
that time showed bilateral basal ganglion infarcts. carotid studies then showed
minimal plaque, right greater than left, with no hemodynamic stenosis. at that
time she was sent home on aspirin one time daily, which she has been taking except
for the day prior to admission when she missed her dose.

physical examination
vital signs: temperature 98.6, blood pressure 164/100 in both arms.
heent: examination is clear.
neck: there is a mild right bruit.
lungs: lungs are clear.
abdomen: abdomen is obese with a surgical scar. bowel sounds are present.
neurologic: she is alert and oriented x3. she has difficulty with speech, mostly
lingual sounds. no aphasic symptoms and normal flow, normal rate, and normal
content. no shortness of breath noted. cranial nerves showed right fundi with
sharp disks. pupils are equal and reactive to light. face was symmetric. eye

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