usuals
TRANSCRIPT
8/13/2019 Usuals
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USUALS
CHIEF COMPLAINT: (reason why the patient is in
the clinic)
HISTORY OF PRESENT ILLNESS: (the history
behind the CHIEF COMPLAIN)
his !"#year#old white$blac% &ale$'e&ale
ALLERGIES:
N*A+
No %nown dr,- aller-ies+
No %nown aller-ies+
PAST MEDICAL HISTORY:
Noncontrib,tory+
Insi-ni'icant+ Not si-ni'icant+
.nre&ar%able+
FAMILY HISTORY:
Noncontrib,tory+Insi-ni'icant+
.nre&ar%able+ No 'a&ilial disease %nown+
SOCIAL HISTORY:
Noncontrib,tory+
Insi-ni'icant+
.nre&ar%able+
he patient is a nons&o%er/ occasional alcohol+
No dr,- ,se or ab,se+
Acti0e li'e style+
*rin%s co''ee and rare alcohol+*iet is balance+
REVIEW OF SYSTEMS:
All syste&s re0iewed1 otherwise ne-ati0e+
Noncontrib,tory+
.nre&ar%able+
2yste&s re0iew essentially ne-ati0e+
PHYSICAL EXAMINATION:
3IAL 2I4N2:
5lood press,re1 te&perat,re1 p,lse1 respirations1 heart
rate6oo& air sat,ration is !778+
9ei-ht is+++
Hei-ht is 'eet inches+
A'ebrile+
P,lse o;i&etry is 8 on roo& air+
O;y-en sat,ration is
4ENE6AL:
Alert1 cooperati0e <=#year#old 'e&ale who appears to be
healthy and in no ac,te distress+Alert1 awa%e1 and in no ac,te distress+
Nonto;ic in appearance+
Alert and oriented ;>+
A well#de0eloped1 well#no,rishedAwa%e1 alert1 and answerin- ?,estions appropriately+
2e0erely ill#appearin-
o;ic#appearin-++
A@7 ;>+
HEEN:
Clear+
.nre&ar%able+
Nor&ocephalic atra,&atic+
No 'acial droop+
No ptosis+
PE66LA+P,pils e?,al1 ro,nd1 and reacti0e to li-ht and
acco&&odation+F,nd,scopic e;a& is nor&al+
No nysta-&,s+
3is,al ac,ity is with both eyes+
Intraoc,lar press,re
F,nd,scopic e;a& shows nor&al 0essel distrib,tion+
2he has ',ll ran-e o' &otion in the e;traoc,lar &,scles+
Con,ncti0ae are clear+
2clerae nonicteric1 noninected1 anicteric+
2clerae are clear+
No scleral icter,s+Ears are erythe&ato,s+
y&panic &e&branes are sli-htly d,ll+
EN
He has 'l,id behind the ri-ht ty&panic &e&brane+
he le't one loo%s nor&al+
he nasal passa-es are &ar%edly swollen and the
pharyn; is ,nre&ar%able witho,t postnasal draina-e+ Nares are clear at this ti&e+
Nares are patent+
Oropharyn; is &oist and clear+
Oropharyn; is witho,t lesions+Oropharyn; is clear with -ood -a-+
No si-n o' e;,dates+
Oropharyn; loo%s -ood+
5oth ty&panic &e&branes are nor&al+
he nose is nor&al+
here is no e0idence o' any bleedin-+
he &o,th is nor&al+
M,co,s &e&branes &oist+
Nasal ca0ities are patent+
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NEC
He has no cer0ical adenopathy+
Nec% is s,pple and nontender+
Nec% 0eins are 'lat+
No carotid br,its+9itho,t &enin-eal co&plaints+
No si-ni'icant ly&phadenopathy present+
No n,chal ri-idity+
here is no tenderness to palpation o0er the spino,s processes o' the nec%+
B,-,lar 0eno,s distention
56EA2:
Free o' &asses+
No &asses can be palpated+
CHE2:
Clear to P@A+
Clear to perc,ssion and a,sc,ltation+
No tenderness to palpation
2y&&etrical+
L.N42Chest is clear to a,sc,ltation+
His l,n- so,nds were clear+
2y&&etrical e;pansion+
He is &o0in- air well+
No rales1 wheees1 or rhonchi+
L,n-s are clear posteriorly+
Nor&al breath so,nds+
HEA6:
Heart tones are re-,lar$'air+6e-,lar rate and rhyth&+
No$9ith$9itho,t &,r&,rs1 r,bs1 or -allops
2! and 2< nor&al+
No cardio&e-aly+
A5*OMEN:
2o't1 nontender1 nondistended+ 5owel so,nds are
present+5eni-n+
No hepatospleno&e-aly nor or-ano&e-aly+
Obese and nontender+
No &asses or ascites present+ No si-n o' hernia+
No rebo,nd1 -,ardin-1 or ri-idity+
Acti0e bowel so,nds+
2o't and nontender to palpation witho,t rebo,nd or
-,ardin-+
Prot,berant1 no &asses+
2caphoid and so't+
2,prap,bic tenderness
No 'lan% pain+
6ECAL:
E;a& shows he&e#ne-ati0e stool+
4ENIALIA:
Nor&al &ale -enitalia+anner sta-e
2IN:
9ar& and dry+Clear and 'ree o' any rashes+
2%in is war& to to,ch with no lesions+
3A2C.LA6:
A <D distal p,lses in all e;tre&ities+
2he has !D pittin- pretibial ede&a+
4ood peripheral p,lses incl,din- dorsalis pedis+
5AC:
here is C3A tenderness bilaterally+
9ith no C3A
E6EMIIE2:
No cyanosis1 cl,bbin-1 or ede&a+ No pedal p,lses+
No peripheral p,lses+
2he is &o0in- all e;tre&ities nor&ally+
9ith ',ll ran-e o' &otion+
$ &otor stren-th on all e;tre&ities+
9ith !D pedal p,lses+
No de'or&ity+
No pain1 swellin-1 or la;ity+
Ne-ati0e ;"+
No an%le ede&a+race lower e;tre&ity ede&a+
NE.6OLO4IC:
A&b,lation is nor&al+
here is no ata;ia+
4ait is nor&al+
Ne,rolo-ically non'ocal+
No 'ocal1 &otor1 and sensory de'icits+Cranial ner0es II thro,-h II are -rossly intact+
Intact &otor and sensory e;a&ination+
No cerebellar si-ns are seen+
Cranial ner0e e;a&ination is -rossly intact+A&b,late witho,t di''ic,lty+
Fin-er#nose testin- is within nor&al li&its+
F,ll ran-e o' &otion+
2tren-th is $+
Physiolo-ic+
Cortical and cranial ner0e e;a&s are
6e'le;es are++
*eep tendon re'le;
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P2GCHIA6IC:
Appears sli-htly an;io,s+
Nor&al &entation+
Appears within nor&al li&its+
LA5O6AO6G:
Arterial blood -as: pH1 PCO<1 PO<5icarbonate1 -l,cose1
.rinalysis+CM31 A2O1 E5NA+C5C1 E41 blood che&istry
Chest ;#ray
5.N1 he&o-lobin and he&atocrit co,nt+CMP1 E41 E+
*I2PO2IION:
*ischar-e to ho&e+