Detailed Version
VITALS: Reviewed.
WEIGHT/BMI reviewed.
GEN: Healthy appearing, well-developed, NAD.
PSYCH: Good Judgment. AOx3. Normal memory, mood, and affect.
HEENT
-Head: NC/AT;
-Eyes: PERRL, EOMI. No discharge or redness;
-Ears: External ears are normal. Normal TMs.
-Nose: Normal nares.
-Mouth and throat: MMM. Normal gums, mucosa, palate,. Good dentition.
NECK: Supple, with no masses.
CV: RRR, no m/r/g.
LUNGS: CTAB, no w/r/c.
ABD: Soft, NT/ND, NBS, no masses or organomegaly.
GU: N/A
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.
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;
-Ears: External ears are normal.
-Nose: Normal nares.
-Mouth and throat: MMM. Normal gums, mucosa, palate,. Good dentition.
CV: RRR, no m/r/g.
LUNGS: CTAB, no w/r/c.
ABD: Soft, NT/ND, NBS, no masses or organomegaly.
GU: N/A
SKIN: Warm, well perfused. No skin rashes or abnormal lesions.
MSK: Normal gait. No deformities.
EXT: No clubbing, cyanosis, or edema.
NEURO: Ambulating with no limitations. No focal deficits.