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Duyenova HealthNew encounter

New Encounter

Paste a transcript or shorthand notes. Use synthetic data only.

Pending Orders
Procedures

History of Present Illness

Patient presents to the RCHC acute care facility with complaints of:

Constitutional
HEENT
Cardio / Respiratory
GI / GU
Neuro / Psych
Exposure
Aggravated by
Alleviated by

Review of Systems (Adult)

Constitutional
Eyes
Ears
Nose
Mouth/Throat/Voice
Neck
Respiratory
Cardiovascular
Gastrointestinal
Urinary
Dermatologic/Integumentary
Musculoskeletal
Neurological
Psychiatric
Hematologic/Lymphatic
Genital/Reproductive

Physical Exam (Adult)

VS
GENERAL APPEARANCE
CONSTITUTIONAL
NAD, Awake, Alert, comfortable, cooperative with exam, patient well nourished, well developed
EYES
PERRLA, EOMI
EARS, NOSE, MOUTH, THROAT
hearing grossly intact. Normal lips, normal gums, uvula midline, mucous membranes moist. Head and Face: normocephalic, atraumatic
NECK
Trachea midline
RESP
CV
NL S1, NL S2, regular rate, regular rhythm
CHEST (BREAST)
chest wall symmetric
GASTROINTESTINAL
abdomen soft
LYMPHATIC/HEMATOLOGIC/IMMUNOLOGIC
MUSCULOSKELETAL
BL Upper & lower extremity strength intact, BL muscle strength NL throughout
SKIN
PSYCH
normal mood, normal affect, patient alert and oriented to time, place, and person, judgement and insight intact
NEURO
sensation grossly intact, CN II-XII intact and nonfocal, deep tendon reflexes 2+, bilaterally equal throughout, no pathological reflexes elicited, normal gait, normal station
Back & Spine
GENITOURINARY
Normal external genitalia, speculum exam with closed cervical os, no discharge or bleeding noted. Bimanual exam with normal adenexa, no adenexal or cervical motion tenderness, normal uterus