NAME:

DOB:

CHIEF COMPLAINT:

SUBJECTIVE
HPI-ROS:

The patient is here for pain in her right wrist. She fell and pressed down really hard with her right wrist.

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.
OBJECTIVE

General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.

Head: Normocephalic, no lesions.

Back: Normal curvature, no tenderness.

Extremities: No edema, no erythema. A little bit of bruising and swelling in right wrist, has some
pain when the right wrist is being pushed in the stomach.

Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.

ASSESSMENT
Dx: Pain right wrist (M25.531)
PLAN

1. I ordered an xray for right wrist it might be fractured.

2. I will send an order to Sierra Vista diagnostics for right wrist pain stat x-ray, will call if the
results are in tomorrow.

I, Mark Carnett, DO personally performed the services described in this documentation, as

scribed by in my presence, and it is both accurate and complete.