Notes
Notes - notes.io |
Objective
Vitals: BP 125/82, left arm, seated; P 74, regular; RR 14, unlabored; T 98.3°F, ora
General Survey: Pt. was alert, not distressed, and dressed-well.
Head: Normal Cephalic Skull, W/o noticeable hair loss, No scalp lesions
Eyes: No deformity of pinnae, EOMI (H-Test), PEERLA, Visual fields intact after confrontation, Visual acuity by Snellen chart 20/20 OD OU OS uncorrected, no conjunctiva redness, lid margins clear, no sclera icterus
Ears: External ear canal clear, TM translucent with cone of light present, hearing intact bilaterally finger rub
Nose: Nares patent, septum midline, and turbinate not inflamed, nasal mucosa pink and moist
Sinuses: No tenderness at palpation of sinuses (frontal and maxillary)
Oropharynx: No lip lesions, dentition w/o gum disease, no tongue w/o lesions, pharynx w/o redness, oral mucosa pink and moist
Neck: No thyroid enlargement (normal function), trachea midline, no carotid bruits, and neck symmetrical
Thorax (Inspection): Chest wall w/o deformities, scars or lesions, breathing normal, and normal respiration without accessory muscle use
Lungs: bilaterally CTA, - bronchophony, - egophony, and - whispered pectorilquy
Thorax (Auscultation): Chest wall not tender, Symmetrical chest wall expansion, and PMI --> 5th intercostal space midclavicular
Cardiovascular: Regular rhythm and rate, no S3/S4 sounds, S1/S2 sounds present
Lymphadenopathy: No lymphadenopathy in supraclavicular, axillary or epitrochlear regions
Peripheral vascular: +2/4 bilaterally: ulnar, radial, and brachial; +2/4 bilaterally: popliteal, dorsalis, and posterior tibial, No edema and varicosities in lower extremities
- Capillary Refill is less than 2 seconds
Abdomen: Flat non-distended, no scars & no striae, normal bowel sounds, no abdominal bruits, no tenderness, no abnormal masses, TYMPANIC to percussion in all 4 quadrants, no splenomegaly/hepatomegaly
Assessment: Pt. presented for his wellness visit/annual physical. Allergies controlled on medication. Pt. is generally in good health, up to date in vaccinations/immunization.
Plan: Continue daily exercise and good dietary habits. Follow-up visit established after, basic labs results come back.
|
|
Notes is a web-based application for online taking notes. You can take your notes and share with others people. If you like taking long notes, notes.io is designed for you. To date, over 8,000,000,000+ notes created and continuing...
With notes.io;
- * You can take a note from anywhere and any device with internet connection.
- * You can share the notes in social platforms (YouTube, Facebook, Twitter, instagram etc.).
- * You can quickly share your contents without website, blog and e-mail.
- * You don't need to create any Account to share a note. As you wish you can use quick, easy and best shortened notes with sms, websites, e-mail, or messaging services (WhatsApp, iMessage, Telegram, Signal).
- * Notes.io has fabulous infrastructure design for a short link and allows you to share the note as an easy and understandable link.
Fast: Notes.io is built for speed and performance. You can take a notes quickly and browse your archive.
Easy: Notes.io doesn’t require installation. Just write and share note!
Short: Notes.io’s url just 8 character. You’ll get shorten link of your note when you want to share. (Ex: notes.io/q )
Free: Notes.io works for 14 years and has been free since the day it was started.
You immediately create your first note and start sharing with the ones you wish. If you want to contact us, you can use the following communication channels;
Email: [email protected]
Twitter: http://twitter.com/notesio
Instagram: http://instagram.com/notes.io
Facebook: http://facebook.com/notesio
Regards;
Notes.io Team
