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THORAX & BACK. Observation: symmetrical expansion with respiration. Percussion: θ spinal tenderness, θ CVA (costovertebral angle) tenderness (Comment of findings regarding CVA tenderness under abdomen – see example *.
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.
This sample summative H&P was written by a second‐year medical student from UCF COM Class of 2020 at the end of COP‐2. While not perfect, it best exemplifies the documentation skills students are expected and able to acquire by the end of P‐2: organization,
NP cheat sheet for documenting a physical exam. Learn more from ThriveAP the leading virtual NP transition to practice education.
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.
The Pocket Guide to Physical Examination and History Taking, 7th edition is a concise, portable text that: Describes how to interview the patient and take the health history. Provides an illustrated review of the physical examination. Reminds students of common, normal, and abnormal physical findings. Describes special techniques of assessment ...
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