Head is normocephalic atraumatic bilateral eyes with

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Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.
Respiratory Student Documentation Model Documentation Subjective Pt denies shortness of breath, difficult breathing, wheezing or cough. Pt has history of asthma. Denies sinus pressure or rhinnorhea. Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough. Objective Peak flow x3: FVC 3.91, FEV 3.15= FEV1/FVC ratio of 80.5% Pt in no obvious distress, breathing unlabored, chest symmetrical, rise and fall of chest even. Breath sounds clear and equal bilaterally in all fields. Tympanic resonance to percussion anterior and posterior chest with no dullness. Fremitus normal. Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%. Cardiovascular Student Documentation Model Documentation Subjective Pt denies chest pain, palpitaitons, or edema. No history of anemia Reports no palpitations, tachycardia, easy bruising, or edema.
Student Documentation Model Documentation or easy bruising. Objective S1, S2 heard with normal rate and rythm, no murmurs or gallops noted on auscultation. Pulses present in all extremeties 2+, no thrills. No edema in extremities, PMI MCL 5th intercostal space. Carotid pulsespresent with no bruit. Capillary refill <3 sec in all extremities. No abdominal, iliac, renal or femoral bruits. No JVD. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema. Abdominal Student Documentation Model Documentation Subjective Pt denies any nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort. Reports eating healthier but no change in appetite. No difficulty urinating or excessive urinating. Denies bowel or bladder dysfunction. Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.
Student Documentation Model Documentation Objective Abdomen no visible brusing or lesions, protuberant, and excessive hair around umbilicus. Bowels sounds normoactive in all quadrants. No tenderness, guarding, no masses on deep and light palpation. Tympanic on percussion and no CVA tenderness. Organs

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