Physical assessment and plan
Objective: Physical Examination: [textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"] [textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well-nourished, alert and cooperative, and appears to be in no acute distress."] [textarea cols=80 rows=1 default="HEAD: normocephalic, color consistent tent with upper extremities, skull symmetric, hair evenly distributed, no sinus tenderness, CN V, VII intact.."] [textarea cols=80 rows=1 default="EYES: PERRLA, Extraocular movements intact through all visual fields. vision is grossly intact."] [textarea cols=80 rows=1 default="EARS: External auditory canals and tympanic membranes clear, hearing grossly intact."] [textarea cols=80 rows=1 default="NOSE: No nasal discharge, nares patent, septum midline."] [textarea cols=80 rows=2 default="MOUTH and PHARYNX: Oral cavity and pharynx consistent red color, moist, uvula midline, tonsils not visible past anteroposterior pillars. No inflammation, swelling, or exudate. Not malodorous, no lesions. Teeth and gingiva in good general condition, CN VII, IX, X motor functions intact, did not test sensory."] [textarea cols=80 rows=1 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."] [textarea cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4, or murmurs. The rhythm is regular. No carotid bruits, no peripheral edema, cyanosis, or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."] [textarea cols=80 rows=2 default="LUNGS: Symmetric rise and fall with breathing, no accessory muscle use, resonance with percussion over posterior and lateral chest walls, no scapular, subscapular, or axillary lymphadenopathy noted, Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds, no pulsations, heaving, or crepitation. Chest wall stable without tenderness. No thrill, heaves, or pulsations over the precordium."] [textarea cols=80 rows=2 default="ABDOMEN: Skin consistent with surrounding tissue, no pulsations, deformities, or movements noted, bowel sounds + all 4 quadrants. Soft, non distended, non-tender. No guarding, anticipation, or rebound. No masses or deformities. unable to palpate liver, kidneys, or spleen. Negative Murphey's sign."] [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, negative Romberg."] [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."] [textarea cols=80 rows=2 default="UPPER EXTREMITIES: Skin consistent with neck/face, skin warm, full ROM to fingers, wrist, elbows, and shoulder without crepitus or anticipation. Negative Schamroth sign, No significant deformity or joint abnormality. No edema. Radial and brachial pulses 2+ bilaterally. No varicosities."] [textarea cols=80 rows=1 default="BACK: Skin color consistent with race and surrounding tissue, spine midline, thorax symmetrical, shoulders even, no CVA tenderness."] [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, Color uniform with legs and contralateral foot, normal sensation, capillary refill less than 2 seconds without tenderness. No Swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals the normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity, Dp and PT pulses 2+ bilaterally, Hips stable and exhibit full ROM without crepitus, grimace or anticipation from patient."] [textarea cols=80 rows=2 default="NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. Negative Romberg, proprioception intact as demonstrated with finger to thumb maneveurs."] [textarea cols=80 rows=1 default="SKIN: Skin normal appropriate for race, smooth texture and elastic turgor snapping back in less than 2 seconds. No lesions or eruptions noted."] [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."] Laboratory and Radiology: [textarea cols=80 rows=1 default="Results/nordered"] Assessment and Plan [textarea cols=80 rows=2 default="#1 Problem"] [textarea cols=80 rows=2 default="#2 Problem"] [textarea cols=80 rows=2 default="#3 Problem"] [textarea cols=80 rows=2 default="#4+ Problem"]
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