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PHYSICAL EXAMINATION . WITH ALL NORMAL FINDINGS. (COMPLETE H&P) GENERAL APPEARANCE: (include general mental status) 45 y/o female who is awake and alert and who appears healthy and looks her stated age. VITALS. Temperature: 37.5° C oral (list the site where the temperature was taken, i.e., oral, rectal, tympanic membrane, axillary)
9 Νοε 2018 · Brief Version. GEN: Healthy appearing, well-developed, NAD. PSYCH: Good Judgment. AOx3. Normal memory, mood, and affect. HEENT: -Head: NC/AT; -Eyes: No discharge or redness;
NP cheat sheet for documenting a physical exam. Learn more from ThriveAP the leading virtual NP transition to practice education.
History of Present Illness. This is the first admission for this 56 year old woman, who states she was in her usual state of good health until one week prior to admission. At that time she noticed the abrupt onset (over a few seconds to a minute) of chest pain which she describes as dull and aching in character.
History and Physical Examination (H&P) Examples. The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations. The students have granted permission to have these H&Ps posted on the website as examples. H&P 1.
A Physical Exam Template is a structured guide used by healthcare providers to systematically document the findings of a patient's physical examination. This template typically includes sections for various body systems, allowing providers to record and organize observations.
DATA BASE SAMPLE: PHYSICAL EXAMINATION WITH ALL NORMAL FINDINGS. GENERAL APPEARANCE: (include general mental status) 45 y/o female who is awake and alert and who appears healthy and looks her stated age. VITALS. Temperature: 37.5° C oral (list the site where the temperature was taken, i.e., oral, rectal, tympanic membrane, axillary)
