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Microsoft Word - Normal_PE_Sample_write-up. 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.
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.
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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. “77 yo woman – swelling of tongue and difficulty breathing and swallowing” H&P 2.
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;
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)
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.
