ID:

CC:

HPI: Tell patients story and include 7 dimensions

PMHx:

PSHx:

Meds:

Allergies:

Family Hx:

Social Hx:

Health Maintenance:

ROS: 2 things from 3 different systems

EXAM
Vitals:
Temp 97.3, BP 120/80, HR 60-100, RR 12-18/BPM

General impression: Patient is in no acute distress, appears comfortable, alert, oriented, well-
groomed and maintained eye contact

HEENT: Normocephalic. Moist oral mucosa, no scleral icterus, white conjunctiva. Pupils equal,
round, and reactive to light. Extraocular movements intact. No tenderness from palpation of
pinna, external auditory canal is free of erythema bilaterally, tympanic membrane is greyish
yellow in color and not swollen bilaterally. No obvious erythema or lesions on the neck. No
supraclavicular, anterior cervical, posterior cervical, postauricular, preauricular, submandibular,
nor submental lymphadenopathy. Posterior oropharynx is erythematous. Non-tender, non-
enlarged, smooth thyroid without nodules.

Skin: No obvious skin lesions or abnormalities on chest, back, head, neck and extremities. Skin
appears healthy and intact.

Pulmonary: normal RR, normal vesicular sounds bilaterally A&P, no crackles rhonchi or
wheezing. Clear to percussion AP.
CV: Normal S1 and S2 regular rate and rhythm, no murmurs. Carotids 2+ bilaterally, radial 2+
bilaterally, anterior tibialis 2+ bilateral and dorsalis pedis 2+ bilaterally, no JVD

GI: No abdominal pain, no gastroesophageal reflux, no lesions or masses on skin on abdomen.

Percussion is tympanic on the 4 quadrants of stomach. No tenderness to palpation in all
quadrants. Liver is with normal limits, splenomegaly is not appreciated upon palpation.

Neuro: Bilateral shoulder abduction and adduction 5/5, bilateral flexion/extension on forearms
5/5. Bilateral hip flexion and extension 5/5, bilateral leg extension and flexion strength 5/5,
bilateral wrist flexion/extension strength is 5/5, bilateral dorsiflexion and plantar flexion is 5/5.
Bilateral bicep tendon reflex is +2, bilateral triceps tendon reflex +2, bilateral brachioradialis
reflex is +2, bilateral knee jerk is 2+, bilateral Achilles tendon reflex +2, Babinski reflex is
negative with flexion of toes.
Cranial nerves:
Motor/muscle strength:
Reflexes:
Sensation:
Coordination:
Gait:
Additional Examination:

Problem List

Assessment Statement

Diagnosis