SUBJECTIVE

HPI-ROS:
The patient is here for…

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.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use
of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
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

PLAN
1.