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I have interviewed & examined the patient, & confirmed and agree with the history, examination, assessment & plan of Dr. ____________________________. HISTORY:
ROS (
___ General weight loss, fevers, chills, night sweats ___ Eyes - poor vision, pain ___ ENT - sore throat, pain, runny nose, dysphagia ___ CV - pain, palpitations, hypo/hypertension ___ Resp - dyspnea, cough, tachypnea, wheezing ___ GI - pain, nausea, vomiting, diarrhea, constipation ___ GU - pain, bleeding, incontinent, nocturia, smell
CV
Lungs GI
Lymphatic
Element ______P, _________BP, ____R, ______T, __General __Conjunctivae, lids, pupils & irises __ Fundoscopic __Ears & nose, external canals & TMs __Nasal mucosa, septum & turbinate __Lips, gums, teeth __Oropharynx, oral mucosa, salivary glands __Hard & soft palates, tongue, tonsils & post. pharynx __Thyroid __Neck __Breasts & axillae __Palpation & auscultation of heart __Carotid art. __Abd aorta __Fem art. __Pedal pulses __Extremities for edema &/or varicosities __Resp effort __Percussion & auscultation of lung __Abdomen - note presence of masses or tenderness __Liver & spleen __Anus, perineum, rectum, sphincter tone, FOBT __Scrotal contents __Penis __Prostate __Gait & station __Digits, nails __Joints, bones, muscles __ROM, Stability __Palpate skin (edema) & SQ tissue __Cranial nerves __ Strength & tone __DTRs __Sensation __Cerebellum __Judgment & insight __Mood & affect __Orientation to time place, person __Recent & remote memory __Lymph nodes in 2 or more areas
Results (
ASSESSMENT:
Current Medications
Problem: 1.
Plan:
2.
3.
4.
5.
6. Disposition/Discharge Planning
___________________________________________________ .