PT1

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT2

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT3

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT4

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT5

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT6

The patient with a history of ____ presents to the ED for

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT7

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT8

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT9

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT10

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT11

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT12

The patient with a history of ____ presents to the ED for ____.

Denies
GENERAL: Awake, pleasant, cooperative, oriented
HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT13

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT14

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT15

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT16

The patient with a history of ____ presents to the ED for

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT17

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT18

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT19

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT20

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT21

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT22

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT23

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT24

The patient with a history of ____ presents to the ED for

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT25

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT26

The patient with a history of ____ presents to the ED for ____.

Denies
GENERAL: Awake, pleasant, cooperative, oriented
HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT27

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT28

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT29

The patient with a history of ____ presents to the ED for ____.

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
PT30

The patient with a history of ____ presents to the ED for

Denies

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy
___________________________________________________
TEMPLATE

The patient with a history of ____ presents to the ED for

Denies

Constitutional: No fever, no chills.

Eyes: No visual changes, no eye pain, no discharge.
ENMT: No hearing changes, no pain, no discharge, no infections. No neck pain, no stiffness.
Cardiac: No chest pain, no SOB, no edema. No chest pain with exertion.
Respiratory: No cough, no respiratory distress. No hemoptysis.
GI: No nausea, no vomiting, no diarrhea, no abdominal pain.
GU: No dysuria, no frequency.
MS: No myalgia, no muscle weakness, no joint pain, no back pain.
Neuro: No headache, no weakness, no LOC.
Skin: No skin rash.
Endocrine: No polyuria, no polydipsia.
GENERAL: Awake, pleasant, cooperative, oriented
HEENT: PERRL, Extra ocular movements intact, moist mucous membranes, no icterus, oropharynx NL,
nares NL
CARDIAC: Normal S1 and S2, no murmur, regular rate and rhythm.
RESP: Lungs clear to auscultation, no Ret, chest wall non tender. No increased work of breathing.
ABD: Tenderness-none, no pulsating masses
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy

________________________________________________
PEDS EXAM

GENERAL: Laughs and smiles, very active in the ED

HEENT: PERRL, extra ocular movements intact, moist mucous membranes, no icterus, Oral-pharynx NL,
nares NL
CHEST: Cardiac: Normal S1 and S2, no murmurs, rubs or gallops
RESP: Lungs clear to auscultation throughout, no retractions or increased work of breathing
ABD: Soft, nontender
BACK: Non tender, no costovertebral angle tenderness
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No rashes over visualized skin, normal color and skin turgor
NEURO: Gross motor normal, gross sensation intact
NECK: Non tender, full ROM, no gross abnormalities
LYMPH: No lymphadenopathy

GENERAL INFANT (FEMALE)

GENERAL: Awake, looks around, very active in ED, well hydrated, non toxic
HEENT: PERRL, extra ocular movements intact, grossly intact, moist mucous membranes, no icterus, soft
fontanelle
CHEST: Normal S1 and S2, no murmurs, lungs CTA, no Ret, no grunting
ABD: Tenderness-none, no hepatomegaly, bowel sounds NL
BACK: non tender, no defects
EXTREMITY: Gross motor normal, moves all extremities x 4
GU: Normal, no hernias
SKIN: No pallor/rashes, no mottling, warm & moist, brisk cap refill
NEURO: Gross motor normal, moves all extremities, gross sensation intact
NECK: Full ROM, no gross abnormalities
LYMPH: No lymphadenopathy

GENERAL INFANT (MALE)

GENERAL: Awake, looks around, very active in ED, well hydrated, non toxic
HEENT: PERRL, extra ocular movements intact, grossly intact, moist mucous membranes, no icterus, soft
fontanelle
CHEST: Normal S1 and S2, no murmurs, lungs CTA, no Ret, no grunting
ABD: Tenderness-none, no hepatomegaly, bowel sounds NL
BACK: Non tender, no defects
EXTREMITY: Gross motor normal, moves all extremities x 4
GU: Normal, no hernias, no evidence torsion
SKIN: No pallor/rashes, no mottling, warm & moist, brisk cap refill
NEURO: Gross motor normal, moves all extremities, gross sensation intact
NECK: Full ROM, no gross abnormalities
LYMPH: No lymphadenopathy

RECTAL: No external hemorrhoids, no rectal masses, normal rectal tone, no stool impaction, no red
blood, heme negative stool

PELVIC: external genitalia NL, no blood or discharge in the vaginal vault, cervix closed, and without
visible lesion, no adnexal tenderness or fullness, no uterine tenderness or masses

GENERAL: Awake, pleasant, cooperative, oriented

HEENT: Extra ocular movements intact, moist mucous membranes, no icterus
CARDIAC: Regular rate and rhythm.
RESP: No increased work of breathing.
EXTREMITY: Normal active full ROM throughout all extremities, no tenderness, appearance normal
SKIN: No pallor/rashes, warm & moist
NEURO: No gross abnormalities, major muscle groups 5/5, gross sensory intact