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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)
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.
Physical Examination: Always begin with the vital signs. These should include; o Temperature o Pulse o Blood pressure o Respiratory rate o Pain (10‐point scale rating) Pulse oximetry when available: include the percentage of supplemental O2. If room air, document this. EXAMPLE: O2 Saturation: 88% on room air, 95% on 2 liter nasal canula.
Physical Exam: Vitals: T 98.5, HR 68, BP 126/85, RR 16. General Appearance: Patient is a ill-appearing, well-nourished man in no acute distress. Skin: Macular rash in the pre-auricular area. No pallor. Normal texture, normal turgor, warm, dry. Eyes: Normal pink mucosa with no signs of pallor, no scleral icterus.
9 Νοε 2018 · SKIN: Warm, well perfused. No skin rashes or abnormal lesions. MSK: No deformities or signs of scoliosis. Normal gait. EXT: No clubbing, cyanosis, or edema. NEURO: Ambulating with no limitations. Normal muscle strength and tone. No focal deficits.
History of Present Illness: Ms J. K. is an 83 year old retired nurse with a long history of hypertension that was previously well controlled on diuretic therapy. She was first admitted to CPMC in 1995 when she presented with a complaint of intermittent midsternal chest pain.
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