USUALS CHIEF COMPLAINT: (reason why the patient is in the clinic) HISTORY OF PRESENT ILLNESS: (the history behind

the CHIEF COMPLAIN ) his !"#year#old white$blac% &ale$'e&ale( ALLERGIES: N)*A+ No %nown dr,- aller-ies+ No %nown aller-ies+ PAST MEDICAL HISTORY: Noncontrib,tory+ Insi-ni'icant+ Not si-ni'icant+ .nre&ar%able+ FAMILY HISTORY: Noncontrib,tory+ Insi-ni'icant+ .nre&ar%able+ No 'a&ilial disease %nown+ SOCIAL HISTORY: Noncontrib,tory+ Insi-ni'icant+ .nre&ar%able+ he patient is a nons&o%er/ occasional alcohol+ No dr,- ,se or ab,se+ Acti0e li'e style+ *rin%s co''ee and rare alcohol+ *iet is balance+ REVIEW OF SYSTEMS: All syste&s re0iewed1 otherwise ne-ati0e+ Noncontrib,tory+ .nre&ar%able+ 2yste&s re0iew essentially ne-ati0e+ PHYSICAL EXAMINATION: 3I AL 2I4N2: 5lood press,re1 te&perat,re1 p,lse1 respirations1 heart rate( 6oo& air sat,ration is !778+ 9ei-ht is+++ Hei-ht is ::: 'eet ::: inches+ A'ebrile+ P,lse o;i&etry is ::8 on roo& air+ O;y-en sat,ration is( 4ENE6AL: Alert1 cooperati0e <=#year#old 'e&ale who appears to be healthy and in no ac,te distress+ Alert1 awa%e1 and in no ac,te distress+ Nonto;ic in appearance+ Alert and oriented ;>+ A well#de0eloped1 well#no,rished( Awa%e1 alert1 and answerin- ?,estions appropriately+ 2e0erely ill#appearin-( o;ic#appearin-++ A@7 ;>+ HEEN : Clear+ .nre&ar%able+ Nor&ocephalic atra,&atic+ No 'acial droop+ No ptosis+ PE66LA+ P,pils e?,al1 ro,nd1 and reacti0e to li-ht and acco&&odation+ F,nd,scopic e;a& is nor&al+ No nysta-&,s+ 3is,al ac,ity is :::: with both eyes+ Intraoc,lar press,re( F,nd,scopic e;a& shows nor&al 0essel distrib,tion+ 2he has ',ll ran-e o' &otion in the e;traoc,lar &,scles+ ConA,ncti0ae are clear+ 2clerae nonicteric1 noninAected1 anicteric+ 2clerae are clear+ No scleral icter,s+ Ears are erythe&ato,s+ y&panic &e&branes are sli-htly d,ll+ EN He has 'l,id behind the ri-ht ty&panic &e&brane+ he le't one loo%s nor&al+ he nasal passa-es are &ar%edly swollen and the pharyn; is ,nre&ar%able witho,t postnasal draina-e+ Nares are clear at this ti&e+ Nares are patent+ Oropharyn; is &oist and clear+ Oropharyn; is witho,t lesions+ Oropharyn; is clear with -ood -a-+ No si-n o' e;,dates+ Oropharyn; loo%s -ood+ 5oth ty&panic &e&branes are nor&al+ he nose is nor&al+ here is no e0idence o' any bleedin-+ he &o,th is nor&al+ M,co,s &e&branes &oist+ Nasal ca0ities are patent+

NEC) He has no cer0ical adenopathy+ Nec% is s,pple and nontender+ Nec% 0eins are 'lat+ No carotid br,its+ 9itho,t &enin-eal co&plaints+ No si-ni'icant ly&phadenopathy present+ No n,chal ri-idity+ here is no tenderness to palpation o0er the spino,s processes o' the nec%+ B,-,lar 0eno,s distention( 56EA2 : Free o' &asses+ No &asses can be palpated+ CHE2 : Clear to P@A+ Clear to perc,ssion and a,sc,ltation+ No tenderness to palpation( 2y&&etrical+ L.N42 Chest is clear to a,sc,ltation+ His l,n- so,nds were clear+ 2y&&etrical e;pansion+ He is &o0in- air well+ No rales1 wheeCes1 or rhonchi+ L,n-s are clear posteriorly+ Nor&al breath so,nds+ HEA6 : Heart tones are re-,lar$'air+ 6e-,lar rate and rhyth&+ No$9ith$9itho,t &,r&,rs1 r,bs1 or -allops( 2! and 2< nor&al+ No cardio&e-aly+ A5*OMEN: 2o't1 nontender1 nondistended+ 5owel so,nds are present+ 5eni-n+ No hepatospleno&e-aly nor or-ano&e-aly+ Obese and nontender+ No &asses or ascites present+ No si-n o' hernia+ No rebo,nd1 -,ardin-1 or ri-idity+ Acti0e bowel so,nds+ 2o't and nontender to palpation witho,t rebo,nd or -,ardin-+ Prot,berant1 no &asses+ 2caphoid and so't+ 2,prap,bic tenderness No 'lan% pain+

6EC AL: E;a& shows he&e#ne-ati0e stool+ 4ENI ALIA: Nor&al &ale -enitalia+ anner sta-e( 2)IN: 9ar& and dry+ Clear and 'ree o' any rashes+ 2%in is war& to to,ch with no lesions+ 3A2C.LA6: A <D distal p,lses in all e;tre&ities+ 2he has !D pittin- pretibial ede&a+ 4ood peripheral p,lses incl,din- dorsalis pedis+ 5AC): here is C3A tenderness bilaterally+ 9ith no C3A( EE 6EMI IE2: No cyanosis1 cl,bbin-1 or ede&a+ No pedal p,lses+ No peripheral p,lses+ 2he is &o0in- all e;tre&ities nor&ally+ 9ith ',ll ran-e o' &otion+ F$F &otor stren-th on all e;tre&ities+ 9ith !D pedal p,lses+ No de'or&ity+ No pain1 swellin-1 or la;ity+ Ne-ati0e ;"+ No an%le ede&a+ race lower e;tre&ity ede&a+ NE.6OLO4IC: A&b,lation is nor&al+ here is no ata;ia+ 4ait is nor&al+ Ne,rolo-ically non'ocal+ No 'ocal1 &otor1 and sensory de'icits+ Cranial ner0es II thro,-h EII are -rossly intact+ Intact &otor and sensory e;a&ination+ No cerebellar si-ns are seen+ Cranial ner0e e;a&ination is -rossly intact+ A&b,late witho,t di''ic,lty+ Fin-er#nose testin- is within nor&al li&its+ F,ll ran-e o' &otion+ 2tren-th is F$F+ Physiolo-ic+

Cortical and cranial ner0e e;a&s are( 6e'le;es are++ *eep tendon re'le;

P2GCHIA 6IC: Appears sli-htly an;io,s+ Nor&al &entation+ Appears within nor&al li&its+ LA5O6A O6G: Arterial blood -as: pH1 PCO<1 PO<

5icarbonate1 -l,cose1
.rinalysis+

CM31 A2O1 E5NA+ C5C1 E)41 blood che&istry Chest ;#ray 5.N1 he&o-lobin and he&atocrit co,nt+ CMP1 E)41 E +
*I2PO2I ION: *ischar-e to ho&e+