Psychiatry & Psychology
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Review of Systems:<br>[textarea cols=80 rows=1 default="SKIN: no rashes, bruising, nail or hair changes"]<br>[textarea cols=80 rows=1 default="EYES: no blurring/double vision/spots."]<br>[textarea cols=80 rows=1 default="THROAT: no pain/trouble swallowing."]<br>[textarea cols=80 rows=1 default="NECK: no painful nodes."]<br>[textarea
cols=80 rows=1 default="ENDOCRINE: no tremor/palpitations/heat or cold
intolerance/unusual fatigue; no polyuria/polydipsia/polyphagia"]<br>[textarea cols=80 rows=1 default="RESPIRATORY: no cough/sputum/SOB/chest pain."]<br>[textarea cols=80 rows=1 default="CARDIOVASCULAR: no CP/heaviness/jaw or arm pain/palpitations/leg pain with exercise/edema."]<br>[textarea cols=80 rows=1 default="GASTROINTESTINAL: no constipation/diarrhea/blood in stool/melena."]<br>[textarea cols=80 rows=1 default="GENITOURINARY: no dysuria/frequency/blood in urine/incontinence"]<br>[textarea cols=80 rows=1 default="MUSCULOSKELETAL: no pain/swelling in muscles or joints."]<br>[textarea cols=80 rows=1 default="NEUROLOGICAL: no weakness, headache, or other pain."]<br>[textarea cols=80 rows=1 default="PSYCHIATRIC: no depression/anxiety/hallucinations"]<br>Medications: <br>[textarea cols=80 rows=5 default="medication name/dose/indication/duration"]<br>Allergies and Medication Intolerances: <br>[textarea cols=80 rows=1 default="medication or substance and reaction"]<br>Preventive Care Services: <br>[textarea cols=80 rows=1 default="dates and results of screening tests and exams"]<br>Advance Directives: <br>[textarea
cols=80 rows=1 default="living will and/or durable power of attorney
for health care/identify surrogate decision maker"]<br>-----------------------------------------------<br>Physical Examination<br>[textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"]<br>[textarea
cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well
nourished, alert and cooperative, and appears to be in no acute
distress."]<br>[textarea cols=80 rows=1 default="HEAD: normocephalic."]<br>[textarea cols=80 rows=1 default="EYES: PERRL, EOMI. Fundi normal, vision is grossly intact."]<br>[textarea cols=80 rows=1 default="EARS: External auditory canals and tympanic membranes clear, hearing grossly intact."]<br>[textarea cols=80 rows=1 default="NOSE: No nasal discharge."]<br>[textarea
cols=80 rows=2 default="THROAT: Oral cavity and pharynx normal. No
inflammation, swelling, exudate, or lesions. Teeth and gingiva in good
general condition."]<br>[textarea cols=80 rows=1 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]<br>[textarea
cols=80 rows=3 default="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."]<br>[textarea cols=80 rows=2
default="LUNGS: Clear to auscultation and percussion without rales,
rhonchi, wheezing or diminished breath sounds."]<br>[textarea cols=80
rows=2 default="ABDOMEN: Positive bowel sounds. Soft, nondistended,
nontender. No guarding or rebound. No masses."]<br>[textarea cols=80
rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact
spine and extremities. No joint erythema or tenderness. Normal muscular
development. Normal gait."]<br>[textarea cols=80 rows=2 default="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."]<br>[textarea cols=80 rows=2
default="EXTREMITIES: No significant deformity or joint abnormality. No
edema. Peripheral pulses intact. No varicosities."]<br>[textarea cols=80
rows=5 default="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."]<br>[textarea cols=80 rows=2
default="NEUROLOGICAL: CN II-XII intact. Strength and sensation
symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar
testing normal."]<br>[textarea cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]<br>[textarea
cols=80 rows=3 default="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."]<br>Laboratory and Radiology: <br>[textarea cols=80 rows=1 default="test, date, result"]<br><br></body></html>
Review of Systems:<br><br><br><br><br><br><br><br><br><br><br><br><br>Medications: <br><br>Allergies and Medication Intolerances: <br><br>Preventive Care Services: <br><br>Advance Directives: <br><br>-----------------------------------------------<br>Physical Examination<br><br><br><br><br><br><br><br><br><br><br><br><br><br><br><br><br><br><br>Laboratory and Radiology: <br><br><br></body></html>

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