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Example:
Patient information
Name: Mr. W.S.
Age: 65
Male gender
Source: Patient
Allergy: none
Current dose: atorvastatin tablet 20 mg, 1 tablet PO at bedtime
PMH: Hypercholesterolemia
The 2018 flu, tetanus, hepatitis A and B vaccines were administered 4 years ago. Surgical history: Appendectomy 47 years ago.
Family history: the father dies 81 without papers
Mother, 88, diabetic, HTN
The girl is still alive, 34 years old, in good health
Social Hx: No history of smoking or using illicit drugs and sometimes alcohol at community events. The old widow, she was alone.
spatula:
Big complaint: “Headaches” which started 2 weeks ago
Symptom Analysis / HPI:
The patient, a 65-year-old man, complained of a headache and had three blood pressure readings, which were 159/100, 158/98 and 160/100, respectively. The patient noticed that the problem started 2 weeks ago and sometimes with dizziness. He says he has been frustrated at work in recent months. The patient may have chest pain, palpitations, shortness of breath, nausea, or vomiting.
Loss:
Composition: Do not have fever or chills. Weakness or reluctance to lose weight. Neurology: Headache and dizziness as described above. Refuse to change LOC. Deny history of tremors or seizures.
HEENT: HEAD: No head injury or LOC replacement accepted. Eyes: Cannot see changes, see eyes, or have blurred vision. Ears: No earache. No hearing or water. Nose: Nasal congestion, congestion. THROAT: Sore throat or sore throat, hoarseness or difficulty swallowing.
Respiratory diseases: the patient may not breathe short, cough or hemoptysis. Cardiovascular disease: chest pain, tachycardia. No orthopnea or nocturnal paroxysm breathing Gastrointestinal: abdominal pain or discomfort. gas, nausea or vomiting
Diarrhea.
Genitourinary: does not accept changes in hematuria, dysuria or frequency. Refusal to start / stop urination or incontinence. Musculoskeletal System: Loss or pain. Don’t click or click. Skin: No color change such as cyanosis or jaundice, and no redness or itching.
Goal information
COMPOSITION: Main characteristics: Temperature: 98.5 ° F, Pulse: 87, Pressure: 159/92 mmhg, RR 20, PO2-98% in ambient air, Ht-6’4 “, Wt 200lb, BMI 25. Announcement of the 0 / ten state.
General side effects: warning and indication of the patient x 3. No severe pain. Neurology: Agility, CNII-XII is absolutely effective and direct to people, places and times. Forgotten without damage to the upper and lower limbs. both sides EU / LE force 5/5.
HEENT: Head: Normal head, atraumatic, symmetrical, insensitive. No tenderness in the maxillary sinuses. Eyes: Lack of coordination, no jaundice, poor visual acuity and extraocular movements. Could not find nystagmus. Ears: Both sides of the canal are free from erythema, edema, or exudate. Both ears are negative and pearl gray with a clear cone. No tenderness in the maxillary sinuses. The wet nasal mucosa does not bleed. Moist oral mucosa without sores. Discreet cap created by running.
Neck: No cervical lymphadenopathy, no jugular vein dilation, no large goiter and replaceable.
Cardiovascular: S1S2, continuous hold and tightening, no noise or gallop closure. Capillary filling
