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Name:
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Pt.
Encounter Number:
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Date:
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Age:
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Sex:
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SUBJECTIVE
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CC:
Reason
given by the patient for seeking medical care “in quotes”
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HPI:
Describe
the course of the patient’s illness, including when it began, character of
symptoms, location where the symptoms began, aggravating or alleviating
factors, pertinent positives and negatives, other related diseases, past
illnesses, and surgeries or past diagnostic testing related to the present
illness.
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Medications:
(List with reason for med )
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PMH
Allergies:
Medication
Intolerances:
Chronic
Illnesses/Major traumas
Hospitalizations/Surgeries
“Have
you ever been told that you have diabetes, HTN, peptic ulcer disease,
asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems,
or psychiatric diagnosis?”
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Family
History
Does
your mother, father, or siblings have any medical or psychiatric
illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN,
cancer, TB, DM, or kidney disease?
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Social
History
Education
level, occupational history, current living situation/partner/marital status,
substance use/abuse, ETOH, tobacco, and marijuana. Safety status
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ROS
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General
Weight
change, fatigue, fever, chills, night sweats, and energy level
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Cardiovascular
Chest
pain, palpitations, PND, orthopnea, and edema
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Skin
Delayed
healing, rashes, bruising, bleeding or skin discolorations, and any changes
in lesions or moles
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Respiratory
Cough,
wheezing, hemoptysis, dyspnea, pneumonia hx, and TB
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Eyes
Corrective
lenses, blurring, and visual changes of any kind
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Gastrointestinal
Abdominal
pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and
black, tarry stools
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Ears
Ear
pain, hearing loss, ringing in ears, and discharge
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Genitourinary/Gynecological
Urgency,
frequency burning, change in color of urine.
Contraception,
sexual activity, STDs
Female: last pap, breast, mammo, menstrual complaints, vaginal discharge,
pregnancy hx
Male: prostate, PSA, urinary complaints
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Nose/Mouth/Throat
Sinus
problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and
throat pain
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Musculoskeletal
Back
pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis
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Breast
SBE,
lumps, bumps, or changes
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Neurological
Syncope,
seizures, transient paralysis, weakness, paresthesias, and black-out spells
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Heme/Lymph/Endo
HIV
status, bruising, blood transfusion hx, night sweats, swollen glands,
increase thirst, increase hunger, and cold or heat intolerance
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Psychiatric
Depression,
anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx
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OBJECTIVE
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Weight
BMI
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Temp
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BP
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Height
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Pulse
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Resp
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General
Appearance
Healthy-appearing
adult female in no acute distress. Alert and oriented; answers questions
appropriately. Slightly somber affect at first and then brighter later.
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Skin
Skin
is brown, warm, dry, clean, and intact. No rashes or lesions noted.
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HEENT
Head
is normocephalic, atraumatic, and without lesions; hair evenly distributed.
Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears:
Canals patent. Bilateral TMs pearly gray with positive light reflex;
landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No
septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no
occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist.
Pharynx is nonerythematous and without exudate. Teeth are in good repair.
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Cardiovascular
S1, S2
with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs.
Capillary refills two seconds. Pulses 3+ throughout. No edema.
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Respiratory
Symmetric
chest wall. Respirations regular and easy; lungs clear to auscultation
bilaterally.
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Gastrointestinal
Abdomen
obese; BS active in all the four quadrants. Abdomen soft, nontender. No
hepatosplenomegaly.
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Breast
Breast
is free from masses or tenderness, no discharge, no dimpling, wrinkling, or
discoloration of the skin.
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Genitourinary
Bladder
is nondistended; no CVA tenderness. External genitalia reveals coarse pubic
hair in normal distribution; skin color is consistent with general
pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum
was inserted; vaginal walls are pink and well rugated; no lesions noted.
Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On
bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned
behind a slightly distended bladder; no fullness, masses, or
tenderness. No adnexal masses or tenderness. Ovaries are nonpalpable.
(Male:
Both testes are palpable, no masses or lesions, no hernia, and no uretheral
discharge.)
(Rectal
as appropriate: No evidence of hemorrhoids, fissures, bleeding, or
masses—Males: Prostrate is smooth, nontender, and free from nodules, is of
normal size, and sphincter tone is firm).
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Musculoskeletal
Full
ROM seen in all four extremities as the patient moved about the exam room.
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Neurological
Speech
clear. Good tone. Posture erect. Balance stable; gait normal.
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Psychiatric
Alert
and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye
contact. Speech is soft, though clear and of normal rate and cadence; answers
questions appropriately.
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Lab
Tests
Urinalysis—pending
Urine
culture—pending
Wet
prep—pending
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Special
Tests
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Diagnosis
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- Include
at least three differential diagnosis
- Final
diagnosis
- Evidence for final diagnosis should be documented in your Subjective
and Objective exams.
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PLAN
including education
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- Plan:
- Further testing
- Medication
- Education
- Nonmedication treatments
- Follow-up
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