ID:
, Date:
, Name:
, Age:
, Gender:
Male
Female
Other
INFORMATION:
, Refferal:
CC:
HPI:
ROS:
NAD
as below
NOTE:
GENERAL:
no
fever
-
,
chills
-
,
night sweats
-
,
anorexia
-
,
wt loss
-
,
fatigue
-
,
malaise
-
.
SKIN:
no
rashes
-
,
lesions
-
,
itching
-
,
dryness
-
,
sweating
-
,
hair loss
-
.
EYES:
no
glasses
-
,
vision problems
-
,
eye discomfort
-
,
eye discharge
-
,
photophobia
-
.
ENT:
no
earache
-
,
ear discharge
-
,
vertigo
-
,
hearing problems
-
,
tinnitus
-
.
no
nose congestion
-
,
nose bleeds
-
.
no
sore throat
-
,
hoarsness
-
,
dysphagia
-
,
odynophagia
-
,
neck lumps
-
.
BREAST:
no
lump
-
,
pain
-
,
discharge
-
.
RS:
no
cough
-
,
sputum
-
,
hemoptysis
-
,
dyspnea
-
,
wheezing
-
.
CVS:
no
chest pain
-
,
palpitation
-
,
dyspnea
-
,
orthopnea
-
,
PND
-
,
syncope
-
,
edema
-
.
GI:
no
abdo pain
-
,
nausea
-
,
vomiting
-
,
diarrhea
-
,
constipation
-
,
bowel habit changes
-
,
jaundice
-
,
hemetemesis
-
,
blood in stool
-
,
tarry stool
-
.
GU:
no
painful urination
-
,
GU discharge
-
,
hematuria
-
,
flank pain
-
,
frequent urination
-
,
nocturia
-
,
incontinence
-
,
hesitancy
-
,
difficulty urinating
-
.
MALE GENITAL:
no
testicular pain
-
,
testicular lump
-
,
genital pain
-
,
genital lesion
-
.
FEMALE GENITAL:
no
amenorrhea
-
,
dysmenorrhea
-
,
menorrhagia
-
,
vaginal bleeding
-
,
pelvic pain
-
,
genital pain
-
,
genital lesion
-
.
MUSCULOSKELETAL:
no
back pain
-
,
joint pain
-
,
joint swelling
-
,
muscle pain
-
,
muscle weakness
-
,
stiffness
-
.
PSYCH:
NEURO:
no
headache
-
,
head injury
-
,
weakness
-
,
numbness
-
,
tingling
-
,
tremor
-
,
seizure
-
,
syncope
-
,
dizziness
-
,
cognitive sx
-
.
HEMATOLOGICAL:
no
easy bruising
-
,
easy bleeding
-
,
lymphadenopathy
-
.
ENDO:
no
cold intolerance
-
,
heat intolerance
-
,
sweating
-
,
excessive thirst
-
,
excessive hunger
-
,
excessive urine
-
,
weight changes
-
.
PAST H/O:
FAMILY H/O:
SOCIAL H/O:
MEDICATIONS:
ALLERGIES:
PHYSICAL EXAM:
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Temp:****** Pulse: ****** RR:****** BP:****** SPO2:****** Gen:****** RS: ***aebe***, ***no rales***, ***no ronchi*** CVS: ***s1,s2 present***, ***no murmur*** AS: ***pa soft***, ***no gaurding/rigidity***, ***no organomegaly*** CNS: cn 2-12: ***intact*** motor: ***no wasting***, ***tone normal***, ***power 5/5 at all joints*** reflexes: ***+2 at all joints***, ***plantar flexor*** sensory: ***normal pain and joint position sensation*** gait: ***normal*** -----
MSE:
Appearance:
alert and oriented to time, place and person
OBTUNDED
DISORIENTED
HYPERALERT
-
,
well kempt
POORLY KEMPT
appropriately dressed
INAPPROPRIATELY DRESSED
appropriately groomed
INAPPROPRIATELY GROOMED
DISHEVELED
-
,
normal posture
SLUMPED
RIGID
TENSE
-
.
Behavior:
calm
RESTLESS
AGITATED
RETARDED
PECULIAR
IMPULSIVE
-
,
interactive
WITHDRAWN
-
,
eye contact good
eye contact AVOIDANT
eye contact INTENSE
eye contact FLEETING
-
.
Attitude:
cooperative
HOSTILE
OVER FRIENDLY
SECRETIVE
EVASIVE
SUSPICIOUS
APATHETIC
EASILY DISTRACTED
FOCUSED
DEFENSIVE
DEMANDING
SEDUCTIVE
-
.
Speech:
spontaneous
NON-SPONTANEOUS
MUTISM
-
,
N reaction time
INCR REACTION TIME
DECR REACTION TIME
VARIABLE
-
,
normal rate
SLOW
POVERTY
PAUCITY
RAPID
OVERTALKATIVE
PRESSURE
-
,
normal volume
LOUD
SOFT
WHISPHER
MONOTONE
-
,
clear rhythm
SLURRED
HESITANT
APHASIC
-
.
Mood reported as:
, inferred as-
euthymic
NOT REPORTED
ANXIOUS
DEPRESSED
DYSPHORIC
IRRITABLE
ELEVATED
EXPANSIVE
ELATED
EUPHORIC
ANGRY
HOSTILE
INDIFFERENT
DETACHED
ANIMATED
-
Affect: quality:
euthymic
ANXIOUS
DEPRESSED
DYSPHORIC
IRRITABLE
ELEVATED
EXPANSIVE
ELATED
EUPHORIC
ANGRY
HOSTILE
INDIFFERENT
DETACHED
ANIMATED
-
,
range normal
BROAD
RESTRICTED
-
,
intensity normal
EXPANSIVE
BLUNTED
FLAT
LABILE
-
,
congruent
INCONGRUENT
-
.
Thought form:
coherent
INCOHERENT
CANNOT BE ASSESSED
NOT ENOUGH SAMPLE
-
,
logical and goal directed
-
CIRCUMSTANTIAL
TANGENTIAL
LOOSENING
FLIGHTS OF IDEAS
.
-
NEOLOGISM
BLOCKING
VERBAL PERSEVERATION
.
Thought content:
no delusion on current evaluation
DELUSION PRESENT
CANNOT BE ASSESSED
-
,
no active suicidal ideations at present
SUICIDAL IDEATIONS PRESENT
DEATH WISHES PRESENT
CANNOT BE ASSESSED
-
.
Perception:
no hallucination on current evaluation
HALLUCINATION
CANNOT BE ASSESSED
-
.
Insight:
present
PARTIAL
POOR
MOSTLY BLAMES OTHERS
DIFFICULTY IN ACKNOWLEDGING PRESENCE OF PSYCHIATRIC SYMPTOMS
CANNOT BE ASSESSED
-
.
Judgment:
intact
IMPAIRED
CANNOT BE ASSESSED
-
.
Cognition:
intact
ABNORMALITIES PRESENT
PENDING
CANNOT BE ASSESSED
-
.
normal attention, concentration, intact ability to recall recent and remote information, normal abstraction
LABS:
DD:
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Drugs:****** Infective:****** Vascular:****** Inflammatory:****** Nutritional:****** Endocrine:****** Metabolic:****** Degenerative:****** Trauma:****** Tumor:****** Seizure:****** Structural:****** Other:****** Psychogenic:******
PLAN:
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Problems:****** Diagnostic plan:****** Psychopharmacological Rx plan:****** Psychological Rx plan:******
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