6åâãâââðJs”{–Â^‹y–stƒh›âââââââââââh‡{–†:€câââââââââââââââ÷IŠunŠ{Œ~Â|hÂM‹t†u•iââââââââââ ²itƒvÂ_†s–stîJŠc‘s{Ž4‘j„4‘j„ââââââââââââââââââââA€abdaAbdominal exam abnormal¿ABDOMEN: On examination of the abdomen there was noted {@INPUT abdominal findings obese abdomen tympany to percussion hepatomegaly splenomegaly RUQ scar midline scar RLQ scar suprapubic scar right flank scar left flank scar superpubic tenderness diffuse tenderness tenderness to palpitation RLQ tenderness rebound tenderness diminished bowel sounds hyperactive bowel sounds muscle guarding muscle rigidity masses hernia }. A abddAbdominal exam detailedVABDOMEN: The abdomen was inspected and the following observations were made: {@INPUT inspection of abdomen rounded appearance flattened appearance surgical scar located at {@INPUT location of surgical scars} increased veins absent umbilicus hernia located at {@INPUT location of hernia} }. Abdomen was auscultated and the following observations made: {@INPUT auscultation of the abdomen normal bowel sounds heard no bruits detected abdominal bruit right femoral artery bruit left femoral artery bruit bilateral femoral bruits sound that are described as {@INPUT description of other sounds} }. Percussion showed {@INPUT percussion findings tympanic percussion tones over epigastrium liver span of 6 cm at right mid clavicular line liver span of {@INPUT number of cm liver span}cm at right mid clavicular line spleen percussed at left maxillary line and not enlarged the following areas {@INPUT percussion abnormalities} }. The abdomen was palpated and the following observations made: {@INPUT Tenderness no tenderness to palpation tenderness was present at {@INPUT location of tenderness} guarding present rebound tenderness }. Palpation of the liver, spleen, kidney, and aorta revealed {@INPUT Palpation no abnormalities the liver was palpated and found to be {@INPUT liver description} the spleen was palpated and found to be {@INPUT spleen description} the kidney was palpated and found to be {@INPUT kidney description} the aorta was palpated and found to be {@INPUT aorta description} a mass found to be {@INPUT describe mass} {@INPUT description of an abnormal palpation} }. A@abdnAbdominal exam normalÚABDOMEN: Bowel sounds are normo-active. Abdomen is soft, non tender without masses, hepatosplenomegaly or abnormal pulsation. There is no guarding or rebound tenderness. Psoas and obturator signs are not present. K€backaBack and spine abnormalBACK: The spine was examined by palpation and inspection and revealed {@INPUT spine description normal vertical with concave curves at cervix and lumbar vertebrae, normal gait and posture, no tenderness or muscular spasm showed lordosis showed kyphosis nontender spine tenderness along {@INPUT tender areas of spine} no muscle spasm muscle spasm full range of motion limited range of motion in {@INPUT limitation of motion in what directions} findings on physical examination do not support symptoms as described by patient} K@backnBack and spine normal±BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasmB€braBreast and thorax exam abnormalBREASTS: Examination of thorax and breasts revealed {@INPUT chest or breast abnormalities thoracic asymmetry surgical scar costochondral tenderness abnormal nipple discharge fibrocystic changes breast mass axillary lymphadenopathy breast tenderness muscle tenderness }. B brdBreast and thorax exam detailedWBREASTS: Inspection of the breasts showed {@INPUT breast inspection bilateral symmetric breasts no dimples dimple present {@INPUT dimple location} mastectomy on left side mastectomy on right side bilateral mastectomy nipples symmetric and erect nipples with the following characteristics: {@INPUT nipple description abnormal} no discharge discharge present with the following characteristics: {@INPUT description of discharge} }. The breast palpation of all quadrants revealed {@INPUT breast palpation findings granular consistency some cystic like changes cystic like changes a dominant mass the presence of {@INPUT describe palpation details} and no palpable axillary nodes and small nodes present and axillary nodes with the following characteristics {@INPUT characteristics of axillary nodes} }. {@INPUT notes on breast exam}. brnBreast and thorax normal exam“BREASTS: No evidence of chest deformity or tenderness. No breast masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy. H€cvaCardiovascular exam abnormal&HEART: Heart murmur {@INPUT(murmur) describe murmurs none systolic diastolic 1/6 2/6 3/6 4/6 5/6 6/6 }. Pulse {@INPUT(rythm) irregularity regular irregular irregularly irregular regularly irregular }. Peripheral edema {@INPUT(edema) edema severity none 1+ 2+ 3+ 4+ }. VESSELS: Exam revealed {@INPUT vascular full and equal pulses pulses absent or diminished }. Carotid exam revealed {@INPUT carotid_findings @SINGLE no bruits bruits on the left bruits on the right }. {@INPUT describe other bruits No other bruits observed Other bruit present {@INPUT describe other bruits}}. Varicosities are {@INPUT Varicosities on which side @SINGLE absent present on the left present on the right }. Swollen and hard veins are {@INPUT swollen veins-which side @SINGLE absent present on the left side present on the right side present on both sides }. Brown pigmentation on lower extremity is {@INPUT brown pigmentation-which side? @SINGLE absent present on the left side present on the right side present on both sides }. H cvdHeart examination detailed2HEART: The examination of the heart included inspection of the chest which revealed {@INPUT Cardiovascular exam: inspection of chest no visible movement of the precordium movement of the precordium at {@INPUT location of precordial movement} }. Palpation of the chest revealed {@INPUT palpation of chest apical impulse location in fifth intercostal space 4 cm from the mid-line apical impulse location in {@INPUT which intercostal space? (third, fourth, etc)} intercostal space {@INPUT cm from mid-clavicular line} cm from the mid-clavicular line no heaves, lifts or thrills {@INPUT describe location of thrill lift or heave} }. The auscultation of the heart revealed {@INPUT heart sounds S1 and S2 without splitting S1 heard best at the base S2 heard best at the apex S2 split in inspiration no murmurs apical impulse timed with radial pulse regular rhythm irregular rhythm systolic murmur heard at {@INPUT systolic murmur location} diastolic murmur heard at {@INPUT diastolic murmur location} a midsystolic click {@INPUT describe other sounds} }. H@cvnCardiovascular exam normalùHEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis, pallor or signs of congestive heart failure. VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. E€entaEars, nose and throat abnormalOEARS: Examination of {@INPUT Affected side right ear left ear both ears} reveals {@INPUT(ears) ear abnormalities normal findings reddened canal swelling cerumen impaction foreign body in ear canal erythematous TM perforated TM bulging TM discharge Weber tuning fork test lateralizes to this side air conduction is greater than bone conduction bone conduction is greater than air conduction }. NOSE: Nose examination reveals {@INPUT(nose) nose abnormalities normal findings epistaxis rhinorrhea purulent discharge sinus tenderness deviated nasal septum }. ORAL CAVITY AND PHARYNX: Oral cavity and pharnyx {@INPUT(throat) mouth and throat abnormalities normal tonsillar inflammation tonsillar exudate pharyngeal inflammation accumulation of mucous teeth in poor general condition absent teeth TMJ tenderness }. E entdEars, nose, and throat detailed, EARS: Examination of external {@INPUT Affected side right ear left ear both ears} reveals {@INPUT Outer ear normal auricles in good alignment no lesions, without masses or tenderness pierced earring on right auricle pierced earring on left auricle bilateral pierced earrings on auricles small amount of wax present impaction which required irrigation pain in the canal pus in the canal and hearing aid was present and hearing of finger rub was positive opposite pinna, tragus and ear canal normal } {@INPUT other abnormalities or characteristics with no other lesions and {@INPUT other findings} }. The right tympanic membrane was visualized and the following was observed: {@INPUT right tympanic membrane normal a gray appearance a yellow appearance a red appearance the light reflex and bony landmarks were visualized and in proper position a retracted drum was noted a bulging drum was noted scaring was present a perforation was present } and {@INPUT other findings no other findings {@INPUT other findings} }. The left tympanic membrane was visualized and the following was observed: {@INPUT left tympanic membrane normal a gray appearance a yellow appearance a red appearance the light reflex and bony landmarks were visualized and in proper position a retracted drum was noted a bulging drum was noted scaring was present a perforation was present } and {@INPUT other findings no other findings {@INPUT other findings} }. NOSE: The nose was inspected and the following observed: {@INPUT findings in nose normal midline septum, without obstruction or discharge a mid-line septum a deviated septum to the left a deviated septum to the right a mucosa that was pink and moist a mucosa that was pale with discharge a mucosa that was inflamed with pus smelling sensation was normal } and {@INPUT other findings no other findings {@INPUT other findings} }. ORAL CAVITY AND PHARYNX: The throat was also examined and the following found: {@INPUT throat normal buccal mucosa pink and moist without lesions teeth with no repair teeth with fillings and dental work absent teeth dentures teeth with damage requiring dental examination uvula in mid-line split uvula gag reflex intact pharynx with tonsils show normal pink color pharynx with absent tonsils shows normal pink color pharynx and tonsils red inflamed pharynx red, inflamed, and exudative changes no hoarseness hoarseness clearly enunciates words has accent has difficulties with words } and {@INPUT other findings no other findings {@INPUT other findings} }. EÀentnEars, nose and throat normalüENT: External auditory canals and tympanic membranes clear, with hearing grossly intact. Nose without obstruction or discharge. Oral cavity and pharynx without inflammation, swelling, exudite or lesions. Teeth and gums in good general condition. Y@eyEye exam normal÷OPHTHALMOLOGIC: Orbits, eyelids, conjunctivae and sclera are benign. Pupils are equal, round, reactive to light and accommodate normally with extraocular movements intact. Vision is grossly intact, and funduscopic examination is unremarkable. Y€eyaEye exam abnormalbEYES: Eyes normal except for {@INPUT eye abnormalites foreign body impaired visual acuity everted eyelid on the {@INPUT which side} {@INPUT other lid abnormalities} strabismus nystagmus blepharitis conjunctivitis chalazion corneal abrasion hordeolum subconjuntival hemorrage arcus senilus lenicular opacity cells in anterior chamber }. Y eydEye exam detailedEYES: External examination of the eye area showed:{@INPUT eye area brows, lids, and lashes intact, absent lashes, conjunctiva is pink without discharge, conjunctiva is pale without discharge, conjunctiva is red with discharge, arcus senilis, glasses on, contacts worn, pupils are equal round react to light and accommodate, extraocular movement is intact, foreign body noted } and the following findings {@INPUT external findings no other abnormalities and the following abnormalities: {@INPUT other abnormalities} }. The fundi were examined and the following was noted:{@INPUT fundi normal red reflex, clear lens, cataract on left, cataract on right, cataract both sides, pink retina, AV ratio of 2:5, AV ratio of {@INPUT AV ratio}, no crossing changes, AV nicking, macula present, optic disc shows cup disc ratio of .3 {@INPUT other findings in fundus} and no other findings. }.1@gel*General, Head, ENT and Lung exams combinedCCONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing G€genaGeneral appearance abnormal GENERAL APPEARANCE: Patient is {@INPUT Body habitus obese overweight cachetic} appears {@INPUT(ill appearing) acutely ill chronically ill uncomfortable dehydrated } in {@INPUT Distress no distress mild distress moderate distress significant distress}. G gend2General appearance or constitutional exam detailed GENERAL APPEARANCE: Patient is {@INPUT Patient is obese in no distress in mild distress in moderate distress in significant distress cachetic emaciated weak requires assistance to walk wheelchair bound somnolent lethargic uncooperative disoriented }. G@gennGeneral Appearance normal˜GENERAL APPEARANCE: The patient is well developed, well nourished, healthy appearing, oriented, alert, awake, cooperative and in no acute distress. 5@geotlcajeGeneral, Head, Eyes, ENT, Neck, Lungs, Cardiovascular, Abdomen, Musculoskeletal normal exams combinedvCONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing . HEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis or pallor VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. ABDOMEN: Bowel sounds are normo-active. Abdomen is soft, non tender without masses, hepatosplenomegaly or abnormal pulsation. There is no guarding or tenderness. MUSCULOSKELETAL: Examination shows no significant weakness or deformity of the musculoskeletal system 6@geotlcamlGeneral, Head, Eyes, ENT, Neck, Lungs, Cardiovascular, Abdomen, Rectal, Genitalia Male normal exams combinedŽCONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing . HEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis or pallor VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. ABDOMEN: Bowel sounds are normo-active. Abdomen is soft, non tender without masses, hepatosplenomegaly or abnormal pulsation. There is no guarding or tenderness. GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge. RECTAL: Good sphincter tone with no anal or rectal lesions.Prostate is normal SKIN: normal color, texture and turgor with no lesions or eruptions. 2@getlcHGeneral, Head, ENT, Neck, Lungs and Cardiovascular normal exams combinedCONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing . HEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis or pallor VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. 3@getlcaIGeneral, Head, ENT, Neck, Lungs, Heart, and Abdomen normal exams combined¼CONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing . HEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis or pallor VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. ABDOMEN: Bowel sounds are normo-active. Abdomen is soft, non tender without masses, hepatosplenomegaly or abnormal pulsation. There is no guarding or tenderness. 4@getlcamcGeneral, Head, ENT, Neck, Lungs, Cardiovascular, Abdomen, and Musculoskeletal normal exams combined)CONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing . HEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis or pallor VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. ABDOMEN: Bowel sounds are normo-active. Abdomen is soft, non tender without masses, hepatosplenomegaly or abnormal pulsation. There is no guarding or tenderness. MUSCULOSKELETAL: Examination shows no significant weakness or deformity of the musculoskeletal system I@ginGastrointestinal normalGI: Abdomen soft and non-tender with no masses, hepatosplenomegaly or abnormal pulsations. Bowel sounds are normoactive. Rectal exam reveals normal sphincter tone, without lesions or masses. Guiac stool is {@INPUT Stool for blood test not performed negative positive} 9@goeatblcarmsnpŠGeneral, Eyes, ENT, Neck, Breasts, Lungs, Cardiovascular, Abdomen, Rectal, Female Pelvic, Musculoskeletal, Skin, Neurological, PsychiatricÛCONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing . HEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis or pallor VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. BREASTS: No breast masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy. ABDOMEN: Bowel sounds are normo-active. Abdomen is soft, non tender without masses, hepatosplenomegaly or abnormal pulsation. There is no guarding or tenderness. PELVIC: Normally developed genitalia with no external lesions or eruptions. Vagina and cervix show no lesions, inflammation, discharge or tenderness. Uterus and adnexa show no deformity, tenderness or masses. RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. SKIN: normal color, texture and turgor with no lesions or eruptions. MUSCULOSKELETAL:normal examination of the muscles and joints SKIN: normal color, texture and turgor with no lesions or eruptions. NEUROLOGICAL: Alert and oriented with grossly normal cranial nerves, sensation, motor strength, coordination and deep tendon reflexes. PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. 7@ goetblcafslGeneral, Eyes, ENT, Neck, Breasts, Lungs, Cardiovascular, Abdomen, Female Pelvic, Skin normal exams combinedÔCONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing . HEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis or pallor VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. BREASTS: No breast masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy. ABDOMEN: Bowel sounds are normo-active. Abdomen is soft, non tender without masses, hepatosplenomegaly or abnormal pulsation. There is no guarding or tenderness. PELVIC: Normally developed genitalia with no external lesions or eruptions. Vagina and cervix show no lesions, inflammation, discharge or tenderness. Uterus and adnexa show no deformity, tenderness or masses. RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. SKIN: normal color, texture and turgor with no lesions or eruptions. 8@ goetlcarmsnp‚General, Eyes, ENT, Neck, Lungs, Cardiovascular, Abdomen, Rectal, Male Genitalia, Musculoskeletal, Skin, Neurological, PsychiatricxCONSTITUTIONAL: The patient is well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Vital signs as noted. HEAD: normocephalic EAR, NOSE AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose reveals no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate or lesion. Lips, teeth and gums are in good general condition. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub, diminished breath sounds, or labored breathing . HEART: Regular sinus rhythm with no significant murmurs, rubs, gallops or clicks. There is no peripheral edema, cyanosis or pallor VESSELS: No varicosities. Pulses are normal and symmetrical without bruits. ABDOMEN: Bowel sounds are normo-active. Abdomen is soft, non tender without masses, hepatosplenomegaly or abnormal pulsation. There is no guarding or tenderness. GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge. RECTAL: Good sphincter tone with no anal or rectal lesions.Prostate is normal SKIN: normal color, texture and turgor with no lesions or eruptions. MUSCULOSKELETAL: Examination shows no significant weakness or deformity of the musculoskeletal system NEUROLOGICAL: Alert and oriented with grossly normal cranial nerves, sensation, motor strength, coordination and deep tendon reflexes. PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. F€gufa-Female genitourinary and pelvic exam abnormal°PELVIC: Pelvic exam was performed revealing {@INPUT Pelvic exam findings vaginal mucosa erythema atrophic vaginal mucosa cervical erosion cervical motion tenderness vaginal leukorrhea bloody discharge other discharge {@INPUT describe discharge appearance} uterus absent enlarged uterus uterine tenderness adnexal mass {@INPUT Describe adnexal mass} adnexa absent adnexal tenderness vulvar ulcer labial ulcer }. F gufd4Female genitourinary and pelvic examination detailed÷PELVIC: The external genitalia showed a normal female pattern with a {@INPUT External genitalia appearance nulliparous multiparous } appearance. The speculum examination showed {@INPUT Speculum exam findings clear discharge white discharge frothy discharge cheesy discharge blood tinged discharge pale cervix pink cervix bluish cervix }. The cervical os was {@INPUT cervical os appearance nulliparous multiparous } in appearance. A bimanual examination showed the uterus to be in a {@INPUT uterus position anteverted position midposition position retroflexed position absence of the uterus }. The uterus was {@INPUT uterine size about 5.5 cm by 8 cm long, about {@INPUT size of uterus} and was firm and round and was soft and round It was significant for: {@INPUT findings abnormal in uterus} }. The adenexa showed {@INPUT adenexa findngs no evidence of masses and was not tender {@INPUT other adenexa findings} }. The rectovaginal examination showed {@INPUT sphincter tone/rectocoels/ hemorrhoids normal sphincter tone decreased sphincter tone a rectocoel a cystocoel hemorrhoidal tissue }. The following procedures were done: {@INPUT tests occult blood negative occult blood positive pap smear done cultures obtained }. F@gufn+Female genitourinary and pelvic exam normalÕPELVIC: Normally developed genitalia with no external lesions or eruptions. Vagina and cervix show no lesions, inflammation, discharge or tenderness. Uterus and adnexa show no deformity, tenderness or masses. M€guma Male genitourinary exam abnormalXGENITALIA: Genital exam revealed {@INPUT male genital abnormalities normal penis and testes no scrotal mass no tenderness urethral discharge no urethral discharge penile lesion {@INPUT Describe penile lesion} varicocele scrotal mass scrotal tenderness tender and swollen epididymis scrotal edema } with {@INPUT hernia no hernia right inquinal hernia left inquinal hernia right femoral hernia left femoral hernia}. Digital rectal exam {@INPUT Rectal not performed unremarkable prostate abnormal {@INPUT Describe prostate abnormality} reveals hemorrhoids weak sphincter tone}. M@gumnGenitourinary exam male normalêGENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge. ha Head Abnormal¿HEAD: Exam normal except for {@INPUT Abnormality of the head evidence of injury {@INPUT type of injury} tender maxillary area tender frontal area skull abnormality facies abnormal }. hnHead normal examFHEAD: The head is normocephalic without evidence of head trauma. L€la%Lungs and respiratory system abnormal¡LUNGS: Auscultation of the lungs revealed {@INPUT Abnormal lung findings rhonchi rales wheezing diminished breath sounds tachypnea labored breathing }. L ld#Lungs and respiratory detailed examLUNGS: The lungs were examined. The inspection and auscultation revealed {@INPUT inspection of lungs AP diameter less then lateral AP diameter more then lateral muscle and respiratory effort is symmetrical with equal excursion increased respiratory effort retractions resonant percussion through out vesicular breath sounds throughout without adventitious sounds even, quiet breathing rhonchi located at {@INPUT rhonchi location} rales located at {@INPUT rales location} {@INPUT other lung findings} }. L@ln#Lungs and respiratory system normalmLUNGS: Clear to ascultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. J ma,Musculoskeletal system (all joints) abnormalMUSCULOSKELETAL: The {@INPUT Joints hands wrists forearms elbows shoulder feet ankles calves knees thighs hips back neck} of the musculoskeletal system were examined and noted were {@INPUT Musculoskeletal abnormalities no abnormalities deformity weakness tenderness on palpitation numbness pain on motion swelling redness limitation of motion bruising instability increased warmth crepitis muscular spasm joint effusion positive straight leg lift findings do not support physical symptoms }. X€mlxa(Musculoskeletal lower extremity abnormalõMUSCULOSKELETAL LOWER EXTREMITY: Examination of {@INPUT Affected Lower Extremity both feet right foot left foot } reveals {@INPUT Affected Toes all toes hallux second toe middle toe fourth toe little toe MTP joint PIP joint DIP joint } {@INPUT Affected Toe normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity not examined tender painful on motion limited range of motion discolored ecchymotic swollen erythematous warm prolonged in capillary filling greater than 2 seconds cyanotic cold to touch pallor hallux valgus hammer toe paronychia macerated interdigitally erythematous interdigitally onychomycosis onychocryptosis abnormal DIP flexion abnormal PIP flexion abnormal MP flexion abnormal MP extension absent {@INPUT which digit absent} deformed {@INPUT describe deformity} abnormal {@INPUT Describe Abnormality} } and the foot {@INPUT Foot normal range of motion, normal sensation without tenderness, swelling, discoloration, atrophy, instability, weakness or deformity opposite side is normal size and symmetry, normal range of motion, normal sensation without tenderness, swelling, discoloration, atrophy, weakness or deformity not examined tenderness pain on motion discoloration ecchymosis swelling erythema warmth prolonged capillary filling decreased sensation pallor cyanosis cold to touch metatarsal tenderness heel tenderness instep tenderness circumscribed thickening of the sole thickening of the thin skin instability weakness deformity {@INPUT Describe deformity} abnormal {@INPUT Describe Abnormality} }; examination of {@INPUT Affected Lower Extremity both ankles right ankle left ankle } {@INPUT Ankle normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or deformity not performed opposite side full range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or deformity pain on motion swelling of ankle discoloration ecchymosis erythema warmth pallor tenderness lateral ankle tenderness medial ankle calcaneofibular ligament tenderness anterior talofibular ligament tenderness posterior talofibular ligament tenderness limited range of motion unable to fully extend unable to fully flex unable to fully invert unable to fully evert crepitus effusion of ankle decreased sensation weakness deformity {@INPUT Describe deformity} abnormal {@INPUT Describe Abnormality} }; examination of {@INPUT Affected Lower Extremity both knees right knee left knee } {@INPUT Knee normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or deformity not performed opposite knee normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or tenderness pain on motion discoloration ecchymosis swelling erythema warmth crepitus limited range of motion inability to fully extend to 0 inability to fully flex to 130 bulge sign of joint effusion on ballottement collateral ligament instability medial ligament instability positive open drawer sign for anterior cruciate ligament instability positive close drawer sign for posterior cruciate ligament instability tender tibial tuberosity decreased sensation weakness deformity {@INPUT Describe deformity} abnormal {@INPUT Describe Abnormality} }; examination of {@INPUT Affected Lower Extremity both hips right hip left hip } {@INPUT Hip normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or deformity not performed opposite side normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or tenderness pain on motion Patrick's test positive with placing foot on opposite patella crepitus discoloration ecchymosis swelling erythema warmth tender over greater trochanter limited range of motion inability to flex 90 inability to flex with knee bent to 135 inability to extend 20 inability to rotate 45 inability to abduct to 45 inability to adduct to 0 decreased sensation weakness Trendelenberg's sign positive with opposite pelvis falling when standing on {@INPUT Standing on which foot} foot deformity {@INPUT Describe deformity} abnormal {@INPUT Describe Abnormality} }; X mlxd:Musculoskeletal lower extremity detailed laceration repairóMUSCULOSKELETAL LOWER EXTREMITY: Examination of {@INPUT affected side right left } {@INPUT Lower extremity location great toe second toe middle toe fourth toe small toe foot ankle tibia knee thigh hip } reveals {@INPUT Describe lesion laceration lesion tumor abscess avulsion abrasion burn} to be {@INPUT Describe Laceration longitudinal transverse stellate avulsed flap circumscribed multiple puncture }, {@INPUT Laceration Length .5 cm 1 cm 2 cm 3 cm 4 cm 5 cm } in length, {@INPUT Depth superficial epidermal subcutaneous above the tendon sheath tendon layer involement 1st degree 2nd degree 3rd degree } depth, on the {@INPUT Surface extensor surface flexor surface anterior surface posterior surface volar surface dorsal surface }, cleansed with {@INPUT Preparation cleansing betadine soap and tap water sterile saline tap water flush}, draped in the usual fashion, injected with {@INPUT Anesthesia no anesthesia required 1% lidocaine with epinephrine 1% lidocaine 2% lidocaine with epinephrine 2% lidocaine 2% marcaine topical}, hemostasis {@INPUT hemostasis not required electrocautery ferrous sulfate }, subcutaneous closure {@INPUT subcutaneous closure not required 3-O chromic 4-O chromin 3-O plain 4-O plain sutures {@INPUT Enter number or description of subcutaneous closure} }, skin closure {@INPUT Skin closure not required 5-O Nylon 4-O Nylon 3-O Nylon staples dermal glue sutures {@INPUT Enter number or description of subcutaneous closure}, }, protective bandages applied in usual manner. Patient instructed to call if full feeling does not return to affected area within 6 hours, keep area dry, cleanse daily with {@INPUT Patient cleansing instruction rubbing alcohol soap and water betadine}, keep protected, report any signs of redness, drainage or pain. Patient instructed to apply {@INPUT Patient Medication application nothing to the affected skin antibacterial cream Neosporin Ointment Bactroban Silvadene cream} mlxn&Musculoskeletal lower extremity normalÌMUSCULOSKELETAL LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity; J@mn*Musculoskeletal system (all joints) normalþMUSCULOSKELETAL: Examination of both hands and feet reveals all fingers and toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity. Examination of both wrists, elbows, forearms, shoulders, ankles, knees, legs, hips and spine reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity. mstudentI am a student›Today you were seen by a medical student. Your experience was {@INPUT experience was outstanding marginal pleasant }This visit was done on{@LONGDATE}U€muxa(Musculoskeletal upper extremity abnormalyMUSCULOSKELETAL UPPER EXTREMITY: Examination of {@INPUT Affected Upper Extremity both hands right hand left hand } reveals {@INPUT Affected Fingers all fingers thumb index middle ring little MCP joint PIP joint DIP joint } {@INPUT Affected Finger normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity not examined tender painful on motion limited range of motion discolored ecchymotic swollen erythematous warm prolonged in capillary filling greater than 2 seconds cyanotic cold to touch pallor joint noise paronychia digital infection flexed locking unable to flex DIP to 80 unable to flex PIP to 120 unable to flex MP to 90 unable to extend MP to 25 unable to abduct thumb to 50 unable to oppose thumb to 35 absent {@INPUT Which digit missing} Heberden's nodes weak in the interosseous muscles Swan neck deformity Boutonniere deformity deformed {@INPUT Describe deformity} abnormal {@INPUT Describe Abnormality} } and hand and wrist {@INPUT Hand and wrist normal range of motion, normal sensation without tenderness, swelling, discoloration, atrophy, instability, weakness or deformity not examined opposite side are normal size and symmetry, normal range of motion, normal sensation without tenderness, swelling, discoloration, atrophy, weakness or deformity tenderness pain on motion limited range of motion discoloration swelling ecchymosis erythematous warmth prolonged capillary filling decreased sensation cyanotic cold to touch positive Snuffbox ganglion cyst Phalen's sign of wrist pain with flexion present Tinel's sign of digital tingling on percussion present inability to ulnar deviate 60 inability to radial deviate 60 inability to flex MP 90{@INPUT MP flexion which digit} inability to extend MP 25 {@INPUT MP flexion which digit} inability to extend wrist 70 inability to flex wrist 90 instability weakness carpal spasm deformity {@INPUT Describe deformity} abnormal {@INPUT Describe Abnormality} }; examination of {@INPUT Affected Upper Extremity both elbows and forearms right elbow and forearm left elbow and forearm } {@INPUT Elbow and Forearm normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or deformity not performed opposite side full range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or deformity tenderness pain on motion unable to fully flex to 0 unable to fully extend to 0 unable to supinate forearm to 90 unable to pronate forearm to 90 swelling erythema warmth crepitus discoloration ecchymoses petechiae Silver fork deformity reversed Silver fork deformity effusion of elbow decreased sensation weakness deformity {@INPUT Describe deformity} abnormal {@INPUT Describe Abnormality} }; examination of {@INPUT Affected Upper Extremity both shoulders right shoulder left shoulder } {@INPUT Shoulder normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity not performed opposite side normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, instability, weakness or deformity pain on motion extension pain flexion pain elevation pain abduction pain external rotation pain internal rotation pain limited range of motion inability to extend to 180 inability to flex to -50 inability to elevate to 180 inability to abduct to 0 inability to externally rotate 90 inability to internally rotate 90 acromio-clavicular tenderness greater tuberosity tenderness subacromial tenderness deltoid tenderness glenohumeral joint tenderness bicipital groove tenderness supraspinatus tenderness of scapula crepitus discoloration ecchymoses swelling erythema warmth deformity clavicle swelling and tenderness clavicle callus formation decreased sensation prolonged capillary filling weakness deformity {@INPUT Describe deformity} abnormal {@INPUT Describe Abnormality} }; U muxd:Musculoskeletal upper extremity detailed laceration repairMUSCULOSKELETAL UPPER EXTREMITY: Examination of {@INPUT affected side right left } {@INPUT Upper extremity location thumb index finger middle finger ring finger little finger hand wrist forearm elbow humerus shoulder } reveals {@INPUT Describe lesion laceration lesion tumor abscess avulsion abrasion burn} to be {@INPUT Describe Laceration longitudinal transverse stellate avulsed flap circumscribed multiple puncture }, {@INPUT Laceration Length .5 cm 1 cm 2 cm 3 cm 4 cm 5 cm } in length, {@INPUT Depth superficial epidermal subcutaneous above the tendon sheath tendon layer involement 1st degree 2nd degree 3rd degree } depth, on the {@INPUT Surface extensor surface flexor surface anterior surface posterior surface volar surface dorsal surface }, cleansed with {@INPUT Preparation cleansing betadine soap and tap water sterile saline tap water flush}, draped in the usual fashion, injected with {@INPUT Anesthesia no anesthesia required 1% lidocaine with epinephrine 1% lidocaine 2% lidocaine with epinephrine 2% lidocaine 2% marcaine topical}, hemostasis {@INPUT hemostasis not required electrocautery ferrous sulfate }, subcutaneous closure {@INPUT subcutaneous closure not required 3-O chromic 4-O chromin 3-O plain 4-O plain sutures {@INPUT Enter number or description of subcutaneous closure} }, skin closure {@INPUT Skin closure not required cautery 5-O Nylon 4-O Nylon 3-O Nylon staples dermal glue sutures {@INPUT Enter number or description of subcutaneous closure}}, protective bandages applied in usual manner. Patient instructed to call if full feeling does not return to affected area within 6 hours, keep area dry, cleanse daily with {@INPUT Patient cleansing instruction rubbing alcohol soap and water betadine}, keep wound protected, report any signs of redness, drainage or pain. Patient instructed to apply {@INPUT Patient Medication application nothing to the affected skin antibacterial cream Neosporin Ointment Bactroban Silvadene cream} muxn&Musculoskeletal upper extremity normalÚMUSCULOSKELETAL UPPER EXTREMITY: Examination of both hands reveals all fingers to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both wrists, elbows, forearms, and shoulders reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity; N€naNeurological exam abnormalÌNEUROLOGICAL: Neurological examination revealed {@INPUT abnormal neurological findings ataxia tremor weakness numbness deep tendon reflexes increased deep tendon reflexes decreased paralysis }. N ndNeurological exam detailed`NEUROLOGICAL: The patient had a {@INPUT gait steady coordinated gait an unsteady uncoordinated gait a slow unsteady gait walks on heels and toes with out problems has difficulty with walking because of {@INPUT problem with walking} }. The cranial nerves were intact. The reflexes were as follows: right biceps: {@INPUT right biceps -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, left biceps: {@INPUT left biceps -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, right triceps: {@INPUT right triceps -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, left triceps: {@INPUT left triceps -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, right forearm: {@INPUT right brachealradialis -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, left forearm: {@INPUT left brachealradialis -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, right patella: {@INPUT right patella -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, left patella: {@INPUT left patella -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, right ankle: {@INPUT right ankle -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }, left ankle: {@INPUT left ankle -4/4 -3/4 -2/4 -1/4 normal 1/4 2/4 3/4 4/4 }. The patient had {@INPUT foot findings/other neuro findings negative Babinski bilaterally positive Babinski on right positive Babinski on left positive Babinski on both sides and presence of sharp sensation on plantar surface and absence of sharp sensation on plantar surface Crainial nerves were intact The following other neurologic findings were found: {@INPUT neuo findings} }. N@nnNeurological exam normal‰NEUROLOGICAL: Alert and oriented with grossly normal cranial nerves, sensation, motor strength, coordination and deep tendon reflexes. O€oa#Opthalmological (eye) exam abnormalbEYES: Eyes normal except for {@INPUT eye abnormalites foreign body impaired visual acuity everted eyelid on the {@INPUT which side} {@INPUT other lid abnormalities} strabismus nystagmus blepharitis conjunctivitis chalazion corneal abrasion hordeolum subconjuntival hemorrage arcus senilus lenicular opacity cells in anterior chamber }. O od$Opthalmological (eyes) detailed examEYES: External examination of the eye area showed:{@INPUT eye area brows, lids, and lashes intact, absent lashes, conjunctiva is pink without discharge, conjunctiva is pale without discharge, conjunctiva is red with discharge, arcus senilis, glasses on, contacts worn, pupils are equal round react to light and accommodate, extraocular movement is intact, foreign body noted } and the following findings {@INPUT external findings no other abnormalities and the following abnormalities: {@INPUT other abnormalities} }. The fundi were examined and the following was noted:{@INPUT fundi normal red reflex, clear lens, cataract on left, cataract on right, cataract both sides, pink retina, AV ratio of 2:5, AV ratio of {@INPUT AV ratio}, no crossing changes, AV nicking, macula present, optic disc shows cup disc ratio of .3 {@INPUT other findings in fundus} and no other findings. }.O@opn!Opthalmological (eye) exam normal÷OPHTHALMOLOGIC: Orbits, eyelids, conjunctivae and sclera are benign. Pupils are equal, round, reactive to light and accommodate normally with extraocular movements intact. Vision is grossly intact, and funduscopic examination is unremarkable. P€paPsychiatric exam abnormalPSYCHIATRIC: The mental examination was performed. The patient{@INPUT mini mental examination had a formal mini mental examination had a mini mental examination of {@INPUT score on mini mental} was oriented to person, place, and time was able to demonstrate good judgement had excellent recent and remote memory intact had the following findings: {@INPUT findings of mental examination} }. C€pcoldThis is a description of a coldÝEARS: Examination of {@INPUT Affected side right ear left ear both ears} reveals {@INPUT(ears) ear abnormalities normal findings reddened canal swelling cerumen impaction erythematous TM perforated TM bulging TM discharge Weber tuning fork test lateralizes to this side air conduction is greater than bone conduction bone conduction is greater than air conduction }. NOSE: Nose examination reveals {@INPUT(nose) nose abnormalities normal findings epistaxis rhinorrhea purulent discharge sinus tenderness deviated nasal septum }. ORAL CAVITY AND PHARYNX: Oral cavity and pharynx {@INPUT(throat) mouth and throat abnormalities normal tonsilar inflammation tonsilar exudate pharyngeal inflammation accumulation of mucous teething teeth in poor general condition absent teeth TMJ tenderness }. LUNGS: Auscultation of the lungs revealed {@INPUT lung findings clear rhonchi rales wheezing diminished breath sounds tachypnea labored breathing }. pnPsychiatric exam normalPSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal. R€rectaRectal exam abnormalGRECTAL: Rectal exam was performed with the following abnormalities: {@INPUT Rectal abnormalities stool visible blood stool occult blood hemorrhoids tender, swollen and firm anal fissures boggy prostrate tender prostrate enlarged prostrate nodular prostrate thrombosed external hemorrhoid reduced sphincter tone }. R@rectnRectal exam normal²RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Stool guiac negative. {@INPUT Sex F-nothing; M-prostate Prostate is not tender, enlarged or nodular} S€sa Skin abnormal\SKIN: Skin examination reveals presence of{@INPUT type lesions macular erythematous papular squamous papulosquamous vessicular } {@INPUT Clinical impression abrasion acneaform eruption atopic dermatitis bite burn Candida carbuncle cellulitis contact dermatitis contusion erysipilas furuncle hematoma herptic lesion impetigo laceration onychocryptosis onychomycosis paronychia pediculosis periungal hematoma puncture skin cancer subungual hematoma Tinea cruris Tinea pedis urticaria vesicular eruptions warts other abnormality {@INPUT Describe skin abnormality} }. S@sn Skin normalLSKIN: Skin normal color, texture and turgor with no lesions or eruptions. T€taNeck and thyroid abnormal#NECK: Neck and thyroid were examined showing {@INPUT(neck) neck abnormalities anterior cervical lymphadenopathy posterior cervical lymphadenopathy neck tenderness diffuse enlargement of the thyroid {@INPUT Size of thyroid} neck rigidity TMJ tenderness {@INPUT other neck finding}}. T tdNeck and thyroid detailed exam NECK: The neck showed {@INPUT neck findings full range of motion limitation of motion no palpable lymph nodes lymph nodes present, small and not irregular normal carotid pulses without bruits carotid with {@INPUT carotid abnormalities} and {@INPUT other abnormal findings of the neck} and no other abnormal findings }. The thyroid was examined. {@INPUT thyroid description The thyroid was in midline The thyroid was deviated and showed no evidence of irregularity and showed {@INPUT abnormalities of thyroid} }. The trachea was {@INPUT trachea placement in midline deviated to the {@INPUT which side} side showed evidence of a former tracheostomy }. T@tnNeck and thyroid normalRNECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.