Chief complaint:

HPI: (name) is a (number) year old (race) male/female with a (__ year history of ) who presents with (problem, length, aggravated by). He/she has had (sxs). With the (sxs), he has (sxs). She states (relevant social hx) His/her father/mother (if relevant) He/she denies (relevant things)

PMH Xdx at age ()

PSH Since child, age, reason

Medications X (dose) (po qday/BID or prn or )

Allergies NKDA or X (effect)

Family history Father: living with or died of

Social history Works as Lives, with whom/pets Smoker (pack year hx, discontinue when) Drnks () No recreational drug use No recent travel

Physical exam:VS: Temp, BP, P, RRGeneral:HEENT: NCAT Scleraicteric or anicteric Conjunctivaepink or pale OP clear and patent, without exudates Oral mucosa moist Neck: JVD Tracheal deviationside No Carotid bruits Carotid pulses Nl for rate/rhythm/volume Cardiac: Nl S1, S2 Nl PMI or diffuse and laterally displaced No m/r/g No costocondral tenderness S3 at apex, S3 heard best at LLD positionPulmonary: CTAB, no rales/ronchi/wheezes Crackles/rales/ronchi heart at (left/right) lung (base/apex) Focal Hyperresonance? Dullness? Focal EA Increased/decreased tactile fremitus Focal whisper increaseAbdominal: Soft, NT, ND abdomen, normoactive bowel sounds Hypoactive/hyperactive bowel sounds Negative psoas, murphys No rebound tenderness/guarding Nl liver span Extremities: (+1/2/3) bilateral/uniulateral pitting edema in ankles radial pulses Nl for R/R/V pedal pulses Nl for R/R/VSkin no rashes, bruises, cuts no jaundice no palmar erythema/spider angioma

Results: None

Assessment and plan (name) is a __ yo (race) (male/female) with history of () who presents with (CC), associated with (PE findings)

medical word: differential diagnosis includes (1,2,3) . presence of (explain rational for 1,2,3) Will order tests (reason) Will instruct patient () follow up visit ()

Aditya Rao, MS-1