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Chiefcomplaint:

HPI:
(name)isa(number)yearold(race)male/femalewitha(__yearhistoryof)who
presentswith(problem,length,aggravatedby).
He/shehashad(sxs).Withthe(sxs),hehas(sxs).
She states (relevant social hx)
His/her father/mother (if relevant)
He/she denies (relevant things)
PMH
Xdx at age ()
PSH

Since child, age, reason

Medications
X (dose) (po qday/BID or prn or )
Allergies
NKDA or X (effect)
Family history
Father: living with or died of
Social history
Works as
Lives, with whom/pets
Smoker (pack year hx, discontinue when)
Drnks ()
No recreational drug use
No recent travel
Physical exam:
VS: Temp, BP, P, RR
General:
HEENT:
NCAT
Scleraicteric or anicteric
Conjunctivaepink or pale
OP clear and patent, without exudates
Oral mucosa moist
Neck:

JVD
Tracheal deviationside
No Carotid bruits
Carotid pulses Nl for rate/rhythm/volume
Cardiac:
Nl S1, S2
Nl PMI or diffuse and laterally displaced
No m/r/g
No costocondral tenderness
S3 at apex, S3 heard best at LLD position
Pulmonary:
CTAB, no rales/ronchi/wheezes
Crackles/rales/ronchi heart at (left/right) lung (base/apex)
Focal Hyperresonance? Dullness?
Focal EA
Increased/decreased tactile fremitus
Focal whisper increase
Abdominal:
Soft, NT, ND abdomen, normoactive bowel sounds
Hypoactive/hyperactive bowel sounds
Negative psoas, murphys
No rebound tenderness/guarding
Nl liver span
Extremities:
(+1/2/3) bilateral/uniulateral pitting edema in ankles
radial pulses Nl for R/R/V
pedal pulses Nl for R/R/V
Skin
no rashes, bruises, cuts
no jaundice
no palmar erythema/spider angioma
Results: None
Assessment and plan
(name) is a __ yo (race) (male/female) with
history of ()
who presents with (CC), associated with (PE findings)

medical word: differential diagnosis includes (1,2,3) . presence of


(explain rational for 1,2,3)
o Will order tests (reason)

o Will instruct patient () follow up visit ()


Aditya Rao, MS-1