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Generic Visit Note
Sep 4, 2016
•
Mark Morgan
categories:
Complete Note
Chief Complaints:
one or more symptoms in patient's words, duration...
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History of Present Illness:
PQRST - Provocative or Palliative maneuvers, symptom Quality, the Region involved, the Severity and Temporal pattern of symptom...
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Past Medical and Surgical History:
chronic illness, important prior illness, operations, injuries, prior hospitalizations
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Family History:
history for first-degree relatives or beyond
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Social History:
place of birth, nationality and ethnicity, marital status, occupations, military history, gender preference, social and economic status, habits, violence and safety, prostheses and in-home assistance
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Review of Systems:
SKIN: no rashes, bruising, nail or hair changes
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EYES: no blurring/double vision/spots.
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THROAT: no pain/trouble swallowing.
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NECK: no painful nodes.
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ENDOCRINE: no tremor/palpitations/heat or cold intolerance/unusual fatigue; no polyuria/polydipsia/polyphagia
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RESPIRATORY: no cough/sputum/SOB/chest pain.
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CARDIOVASCULAR: no CP/heaviness/jaw or arm pain/palpitations/leg pain with exercise/edema.
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GASTROINTESTINAL: no constipation/diarrhea/blood in stool/melena.
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GENITOURINARY: no dysuria/frequency/blood in urine/incontinence
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MUSCULOSKELETAL: no pain/swelling in muscles or joints.
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NEUROLOGICAL: no weakness, headache, or other pain.
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PSYCHIATRIC: no depression/anxiety/hallucinations
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Medications:
medication name/dose/indication/duration
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Allergies and Medication Intolerances:
medication or substance and reaction
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Preventive Care Services:
dates and results of screening tests and exams
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Advance Directives:
living will and/or durable power of attorney for health care/identify surrogate decision maker
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Physical Examination
VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level
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GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
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HEAD: normocephalic.
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EYES: PERRL, EOMI. Fundi normal, vision is grossly intact.
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EARS: External auditory canals and tympanic membranes clear, hearing grossly intact.
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NOSE: No nasal discharge.
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THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition.
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NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
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CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.
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LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
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ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses.
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MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait.
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BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm.
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EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities.
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LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity.
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NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal.
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SKIN: Skin normal color, texture and turgor with no lesions or eruptions.
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PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal.
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Laboratory and Radiology:
test, date, result
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Assessment and Plan
#1 Problem
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#2 Problem
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#3 Problem
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#4+ Problem
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display/hide references
reference:
LeBlond R, Brown D, DeGowin R. DeGowin's Diagnostic Examination, 9e. New York. McGraw Hill; 2009
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