![]() ![]() Patient has erythema and edema involving theįrom the IV infiltrative site on the dorsal aspect of the right hand, extending Pulse rate 102, respiratory rate 24, O2 sat 95%. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.2, blood pressure 104/55, Patient reports producing urine with the IV SOCIAL HISTORY: No cigarette smoking since 2012. įAMILY HISTORY: Not relevant to the presenting complaint. He has been taking ibuprofen for pain controlĪLLERGIES: Significant for penicillin allergy. Patient reports that his breathing has improved Patient had a PICC line put in for IV Lasix. Patient reports that the line has come outĪnd since then the arm is painful, swollen, and red. Receiving IV Lasix through a peripheral line placed on his right upper extremity. Patient is receiving treatment for CHF in the To the hospital with shortness of breath and significant edema. History of mantle cell lymphoma, status post bone marrow transplant in 2009, ![]() HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old gentleman with EXTREMITIES: No peripheral edema, positive for clubbing.Ītthota, Vakula, MD Atthota Consultation Sample No hepatosplenomegaly and no subcutaneous LUNGS: Bilateral scattered wheezing with decreasedīreathing sounds in the right upper lung fields. Icterus, no pallor, oral mucosa is intact. Looks uncomfortable but she is able to respond to vocal commands and she is PHYSICAL EXAMINATION: VITAL SIGNS: Her vitals were reviewed in the EMR, notedįor hypotension with a systolic blood pressure of 80, it is currently 90 when I The right thigh for recent intervention on the hip. He had a dressing on the lateral aspect of LUNGS: Had decreased breathing sounds in both lungįields. Pressure 98/48, saturation 98% on 2 liters. PHYSICAL EXAMINATION: VITALS: Temperature 97, heart rate 60s, blood EXTREMITIES: No peripheral edema.Īl Ustwani P hysical Examination Sample #2 ABDOMEN: Soft, nontender, no hepatosplenomegaly. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98, blood pressure 130/70, heart 68Ĭatheterization and Left Ventriculography Sample (please type on operativeĪl Ustwani P hysical Examination Sample #1 Review of Systems and Physical Examination Sample. Specific formatting, please follow examples below. Tonsillectomy, Adenoidectomy, and Bilateral Myringotomy Tube Insertion Sample. 7Ĭystoscopy with Stent Removal/Replacement Sample. Hysteroscopy with Polypectomy and D and C. You would like to see a sample added to this document, please e-mail the physician’s full name and what type of report you’d like added or a Please note: If you come across a difficult dictator and ![]()
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