Pt outlook No lymphadenopathy +ve Raynaud’s phenomenon

Pt is in no acute stress No carotid bruits +ve mcmurray test

Pt is in mild stress due to back pain No JVD +ve homans sign on right side
Pt seems anxious No thyromegaly / No thyroid +ve Tinnel and Phalen sign
Pt is depressed enlargement Brisk reflex
Pt seems agitated 2+ carotid pulse with good upstroke Non localized tenderness over middle &
Pt appears comfortable bilaterally upper right arm & right shoulder
Pt appears anxious and restlessness Restricted range of motion on flexion,
Pt appears anxious and mild stress Chest extension, abduction
No tenderness on palpation Painful bruises on both arms
HEENT Clear breath sounds bilaterally Right elbow and wrist are normal and
Normal vesicular breathing bilaterally symmetric
Head; Decrease Breath sound on the left lung Unable to assess muscle strength due to
Normocephalic / Atraumatic Two large bruises on left chest pain
No tender to palpitation Rib tenderness DTR’s intact and symmetric
No bruises No crackles or wheezes Sensation intact to pinprick & soft
No stridor or ronchi or rales touch
Eyes; Increase tactile fremitus & decrease Peripheral pulses 2+ and symmetric
PERRLA breath sound on the R.side No asterixis
Normal eye fundus Erythema, tenderness, pain & restricted
No conjunctival hyperemia Heart range of movement of left knee
No conjunctival pallor Regular rate and Rhythm compare to right knee
Pale conjunctiva Tachycardia / Bradycardia Shoulders, elbow, wrist hand & angle
Visual field full to confrontation Normal S1 / S2 joint WNL bilaterally
EOM are intact without diplopia or lid No murmurs
lag No rubs or gallops
No nystagmus Apical impulse not displaced Skin
No papilledema No warmth or erythema or edema
Icteric sclera Abdomen No jaundice
No ptosis Soft nondistended abdomen Excoriations due to scratching
+ve bowel sounds / Hypoactive bowel No spiders / telangiectasia / palmar
Ears; sounds erythema
No cerumen No organomegaly or masses No hair loss or skin changes
Inflamed tympanic memb. No evidence of ascites
Normal tympanic memb. With light No hepatosplenomegaly Neuro
reflex No CVA tenderness Paresthesia, weakness, numbness
No redness to ear canal Direct & rebound RLQ tenderness No neck stiffness
No lymphadenopathy Epigastric tenderness without rebound No Photophobia, auras
No tenderness of auricle or periauricle (PUD) Cranial nerves 2-12 grossly intact
Weber test revealed no lateralization Direct & rebound tenderness in RLQ Mental Status – Allert & oriented x 3,
+ve Rinne test (Air conduction > Bone (PID) spells backwords & recall 3 words
conduction) +ve murphy sign Motor – strength 5/5 throughout
+ve psoas sign Sensation – intact to pinprick and soft
Nose +ve rovsings sign touch bilaterally
Nasal congestion +ve obturator sign DTRs – symmetric 2+ in upper and
Normal oropharynx RLQ guarding lower extremities
Ipsilateral Rhinorrhea C-section scar Cerebellar - +ve Romberg test, finger to
Frontal and maxillary sinus tenderness nose normal, normal Heel knee shin test
on palpation Back Gait – Normal or bradykinetic
Mild paraspinal muscle tenderness +ve Babinski test
Mouth & Throat bilaterally -ve tilt test
No pharyngeal or tonsilar edema Full vertebral range of motion -ve Rinne and weber test
Enlarged Galnds No warmth or erythema -ve Kernig & Brudinski sign
Enlarged tonsils
No excudates Extremities Oby/Gyn
Normal moist mucosal memb. No edema LMP – 2weeksago
Dentition good No tenderness Regular periods or menses
No oromucosal lesions No edema / No cyanosis / No clubbing 28 days cycle. Last for 7 days
No tongue trauma (if seizures) Tremor on outstretched finger tip Menarche at age 13
No dentures Dorsalis pedis pulse felt and equal on Uncomplicated
both sides
Neck; Symmetric 2+ brachial, radial, post.
Supple neck Tibialis, popliteal & dorsalis pedis pulse
Full range of motion in all directions bilaterally
 Polyhydraminous
Menses
Heart
SOB, Pain while breathing ENT
Headache Fever, Chills, sorethroat
Palpitation Cough – productive/ nonproductive
Stroke Painful or not painful cough
Diaphoresis / Night sweats Nasal discharge or congestion
HTN / Hypo Post nasal drip
Hyperlipidemia Sneezing
N/V/D Fascial pressure
Light headedness Swollen glands
Syncope Odynophagia
JVD Malaise, severe fatigue, weakness
Blurred vision Body pain, muscle pain, joint pain
Impending sence of doom Loss of appetite
Fatique Epigastric discomfort
Tremulousness Dyspnea, chest pain, heart burn
Headache Exacerbated by cold weather

Resp. N/V/D
Nasal congestion Aniridia
Wheezing Ipsilateral/ Bilateral
SOB Anisocoria
Chest tightness Mydriasis
Sneezing Miosis
Coryza Ptosis
Cough Anhidrosis
Tachypnea Enophthalamos
Hoarseness Exophthalamos
Dyspnea Amblyopia
Orthopnea Strabismus(Isotropia, Exotropia)
Insomnia Stigmatism
Myopia
Allergies Hyperopia
Urticaria Presbyopia
Erythema Ophthalamoplegia
Pruritus Nystagmus
Angioedema Convergence
Rash Cyclopia

EndoCrine Urinary/ Repro

Polydipsia Hematuria
Urinary urgency
Neuro & Psy Menses
Anxiety Enuresis
Numbness, tingling Penile/Cilitorial Tumescence
Stress, snoring Precocious Puberty
Cold intolerance Anorgasmia
Weight loss Priapism
Agnosia
Chorea
Athetosis Plan Notes
Ballismus Recovering well
Dystonia Advance diet
Hemiparesis Continue to monitor labs
Hypersomnia Apply a warm, moist washcloth to your
Hypochondriasis face several times a day.
Chorea – twitching or jerking Drink plenty of fluids to thin the mucus.
Athetosis – slow movements Get an influenza vaccine each year.
Choreoathetosis Inhale steam 2 - 4 times per day
Tardive kinesia Eat plenty of fruits and vegetable
Catatonia Wash your hands often, particularly
Oby/Gyn after shaking hands with others
 Sinusitis
GERD Drink plenty of fluids to increase
Avoid foods and beverages that may moisture in your body.
trigger symptoms (Alcohol, Caffeine, Eat plenty of fruits and vegetables
Carbonated beverages, Chocolate, Get an influenza vaccine each year.
Citrus fruits and juices, Spicy or fatty Reduce stress
foods) Regular hand wash, particularly after
Avoid garments or belts that fit tightly shaking hands with others.
around your waist Avoid smoke and pollutants
Avoid eating within 2 - 3 hours of Use humidifier to increase moisture in
bedtime your nose and sinuses.
Do not smoke Stay away from triggering factors such
Eat smaller meals as cigarette smoke, pets, cold weather.
Advice to lose weight Get an influenza vaccine each year.
Reduce stress Inhale steam 2 - 4 times per day
Over-the-counter antacids may be used

Arthritis
Rest
Regular Exercise, weight loss 460 – URTI
Avoid any exercise that presents a risk 461 – sinusitis
of falling, or high-impact exercises that 463 – pharyngitis, Laryngitis
may cause fractures. 464 – croup
Apply heat and cold pads 466 – Bronchitis
Eat healthy foods and maintain 493 –
balanced diet 009 – gastroenteritis
Physical therapy to improve muscle 535 – GERD
strength and stiff joints
Massage therapy for pain relief Not on weekends
250 – DM
272 – High Chol.
401 – HTN
DM 244 – Hypothyroidism
Regular exercise every day, weight loss
Drink extra fluids that do not contain
sugar before, during, and after exercise
Monitor blood glucose levels regularly
Advance foot care
Annual eye examination

HTN
Avoid smoking
Limit alcohol - less than 2 standard
drinks per day
Do regular physical activity such as
brisk walking (30 to 60 minutes, at least
3 days a week)
Eat a diet rich in fruits, vegetables, and
low-fat dairy products
Control stress. Physical activity can
help you manage stress.
Eat a healthy diet rich in vegetables and
fruit, low in sodium(salt) and saturated
and trans fat.
Maintain a healthy weight