Clinical presentation for today

Patient Initials:

Pt. Encounter Number: 1

Date:

Age:

Sex:

Allergies: Advanced Directives:

SUBJECTIVE

CC:

HPI (onset, location, duration, characteristics, aggravating factors, relieving factors):

Treatment:

Current Medications:

\

PMH

Childhood Illnesses:

Medical/Psychiatrist:

Surgeries: Injuries:

Preventive Care: Pap Smear: 03/19 (Negative) Mammogram: N/A Colonoscopy: N/A

Obstetric/Gynecological History: Menarche: 12 y/o, LMP: 08/31/19 for 5 days, irregular cycle, plus the spots already described, G2T1P0A1L1, No Hx of STD's, Birth Control: Yes/ IUD, Menopause: N/A, Sexually active: Yes

Family History:

Parents Sibling: Children:

Social History:

ROS YOU MUST CHANGE THE POSITIVE , HERE ALL NEGATIVE

General : Denies weight's changes in the last 6 months, denies weakness, fatigue, fever or chills.

Cardiovascular chest pain or discomfort. Denies palpitations, dyspnea, orthopnea

Skin Normal color, and moist. No presences of moles, rash, or itching. Not change in nails/hair, no cyanosis. Warm and sweated.

Respiratory Denies hemoptysis, dyspnea, or pleuritic pains. No history of lung disease, toxin or pollution exposure.

Eyes Denies problems or changes in his vision; denies double or blurred vision; denies seeing spots. No eyes pain, redness or swelling, and not excessive tearing. No scotomas or flashes. No discharge. Last eyes exam:

Gastrointestinal Denies nausea, emesis, dysphagia, heartburn, jaundice, belching/flatulence. No melena, hemorrhoids, constipation, diarrhea, or food intolerance. No variation in bowel habits. .

Ears Denies difficulty or changes in his hearing. Denies tinnitus, infection, or discharges. No hearing aids.

Genitourinary/Gynecological Report dysuria, frequency or urgency. Denies blood in urine. No urinary urgency, no change in nature of urine. Heavy irregular vaginal bleed

Nose/Mouth/Throat Denies itching, nosebleeds change of sense or smell, No sinus pain. No Bleeding gums, teeth or mouth pain, lesion in mouth or tongue, dry mouth, excessive salivation, and altered taste. No denture prosthesis. Tonsil size, color, and position normal.

Musculoskeletal Denies cramps, joint stiffness, arthritis or gout, limitation of movement, history of musculoskeletal or disk diseases; denies any muscle or joint pain.

Breast Denies pain, rash, discomfort, alteration of nipples, tenderness, or swelling, breast lumps, no nodules, no nipple drainage, no nipple retraction

Neurological Denies history of syncope, seizures, stroke, memory disorder or mood change. No weakness, paralysis, numbness/tingling, tremors or tics, involuntary movements, or coordination problems. No mental disorders or hallucinations.

Heme/Lymph/Endo Denies pain, discomfort, tenderness

Psychiatric Denies depression. Denies memory changes, or suicides attempts. No history of mental illness. Denies suicidal thoughts.

OBJECTIVE

Weight BMI

Temp

BP

Height

Pulse

Resp

PHYSICAL EXAMINATION

General Appearance Well nourished, developed and dressed/groomed, pleasant demeanor, speech clear. Appears to be without discomfort, does not look distressed. Pain level: +3/10 cramps on scale of pain. Normal general appearance. Patient is awake, oriented, and alert. Well-developed and nourished. Patient keeps a normal position and posture without deformities. Patient speaks clear and appropriate in native language. Excellent personal hygiene. No acute distress.

Skin Normal temperature, Hydrated, no rashes or lesions described. Intact, warm, moist, good turgor. Screening for skin cancer performed no precancerous skin lesion.

HEENT Head norm-cephalic. No scar on the head, No tenders, Not erythematous. Not swollen. Neck and Regional Lymph Nodes: Symmetric and supple. Non-tender without cervical lymphadenopathy, masses, or thyromegaly. No carotid bruits, or jugular vein distention. Trachea central, without alterations. Muscles are normal sizes, movable. Eyes: Normal movements, Pupils PERRLA, Funduscopic exam normal. Ears: External auditory Canal normal, Tympanic Membrane normal, No Hearing loss noted. Nose: External aspect is normal. Throat: Lips and oral cavity are within color and structures normal. Teeth and gingiva are normal.

Cardiovascular Normal heart rate and regular rhythm. No tachycardia, no bradycardia. No syncope, no orthopnea. S1 and S2 normal, no S3 nor S4. No gallop, no rubs, no murmurs. No carotid bruit. Peripheral vascular exam normal. No dependent edema. Peripheral pulses present

Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal Abdomen soft, no tenderness, no masses, Bowel sounds presents and normal in the four quadrants. No abnormal aortic pulsations. No ascites. No splenomegaly, no hepatomegaly, nor hernia. No muscle rigidity. No rebound, no guarding. No painful to palpation.

Breast No reported any change. Exam performed with a female medical provider present. There is no axillary adenopathy or tenderness. Breasts appear to be symmetric. There was no nipple discharge or retraction. No breast tissue retraction noted in either the sitting or the supine position. Upon palpation, there were no palpable lumps or bumps and no palpable discharge.

Genitourinary

No costovertebral angle tenderness.

Normally developed outer female genitalia. No perineal or perianal abnormalities are seen. No genital lesion. Speculum examination, IF APPLY:

Bimanual examination, IF APPLY:

Musculoskeletal: Normal ROM throughout major joints. Cervical, thoracic and lumbosacral spine are normal. No edema. No joints and muscle tenderness, no warmth, no erythema. Hips, knees and ankles normal. Normal muscular development. Normal gait.

Neurological: AAOx3.Level of consciousness is normal, Speech Normal, no neurological focalizations, no sensory-perceptions disorders. Cranial Nerves: I-XII grossly intact. No altered mental status.

Psychiatric: Normal, no signs or symptoms of depression, no anxiety, no suicidal ideas. Euthymic, No impairment of thought content.

Lab Tests:

Special Tests

Diagnosis (FINAL DX AND DDx MUST BE SUPPORTTED BY OBJECTIVE AND SUBJECTIVE S/S )

POSITIVE AND NEGATIVE)

Primary Diagnosis - (ICD 10: ) Differential Diagnoses

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2.

3.

PLAN

Laboratory /Diagnostic Test Ordered: Pharmacologic treatment:

Teaching/Education:

Follow-ups/Referrals:

References ( TOTAL OF THREE, ONE FOR EACH DIFERENTIAL DX)