Normal physical exam write up

At the same time, she also noted a strange sensation in her right eyelid. In actual practice, most providers do not document such an inclusive ROS.

At baseline, both pupils should appear symmetric. The patient is a year-old right-handed woman with a history of chronic headaches who complains of acute onset of double vision and right eyelid droopiness three days ago.

Neurologic complaints as per HPI. Obstetrical History where appropriate: The abdomen of the client has an unblemished skin and is uniform in color. The subsequent dilation phase when light removed will be slower than normal. Zoloft 50 mg daily, ibuprofen mg a few times per week, and Vicodin a few times per week.

Imagine that the blood vessels are the branches of a tree. Occasionally, one of the muscles that controls eye movement will be weak or foreshortened, causing one eye to appear deviated medially or laterally compared with the other. You can remember this via the mnemonic: This will direct you towards the optic disc, the point at which the vessels enter the retina along with the head of the optic nerve.

She states that she had an upper respiratory infection with rhinorrhea, congestion, sore throat, and cough about 6 weeks ago. To better examine the sclera, conjunctiva, pupil, cornea or iris, start with the lens identified by a green 4 or 6. It is an important medical-legal document. The pinholes only allow the passage of light which is perpendicular to the lens, and thus does not need to be bent prior to being focused onto the retina.

If present, these symptoms might lead the reader to entertain alternative diagnoses. Corneal responses are intact.


This also includes "pertinent negatives" i. The unaffected eye will respond normally to light shined in either eye, as afferent impulses travel with CN2 and are unaffected.

Depresses the eye when looking laterally Medial rectus: S is known to have poorly controlled diabetes and hypertension. It can be idiopathic or related to injury, infection, tumor or other.

History of present illness: It should constrict normally. When this occurs, the examiner has to determine which is the abnormal eye i.

This requires very small movements.

Complete Head-to-Toe Physical Assessment Cheat Sheet

This is called physiologic anisocoria, in which case the finding is chronic and no other impairments are identified. She denies head trauma, recent illness, fever, tinnitus or other neurologic symptoms.

If, for example, you are describing the course of an otherwise healthy 20 year old who presents with 3 days of cough, fever, and shortness of breath, you can focus on that time frame alone. Physical Exam Vital signs: Ht 5’10” Wt lbs HR 72 RR 16 BP /78 Temp Not measured General: Mr.

H is a depressed-appearing white male in no acute distress. Mental Status Exam Medical Transcription Samples for Medical Transcriptionists. MRI Medical Transcription Sample Reports for Medical Transcriptionists. Nephrology Consultation Medical Transcription Transcribed Sample Report.

Normal Physical Exam Template format for. \\cluster1\home\\1 Training\EMR\SOAP O: (listed are the components of the all normal physical exam) General: Well appearing, well nourished, in no distress.

normal breast exam write up. Introduction breast exam write written history and physical h p serves several purposes it is an important reference document that gives about a patient's history and exam findings at the time his anginal pattern, which is.

A Practical Guide to Clinical Medicine As the story teller you are expected to put your own spin on the write-up. That is, the history is written with some bias. You will be directing the reader towards what you feel is the likely diagnosis by virtue of the way in which you tell the tale.

Physical Exam: Generally begins with a one.

Department of Neurology

The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations. The students have granted permission to have these H&Ps posted on the website as examples.

Department of Neurology Normal physical exam write up
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Sample Write-Ups