PHYSICAL EXAMINATION (Cont’d)                                                   

 

NEUROLOGIC:

• c  Grossly normal cranial nerves II-XI.

• c  Normal 2+ deep tendon reflexes in upper and lower extremities and normal plantar responses.

• c  Normal sensation of pain, touch, temperature, and proprioception (sensibility of position, pressure,

vibration, and negative Romberg test for sensory ataxia) in upper and lower extremities.

c  Except abnormal for

 

PSYCHIATRIC:

• c  Normal judgment and insight.

• c  Normal orientation to time, place, person and well alert.

• c  Normal recent and remote memory [remembering the present illness details and the name of the

past three presidents].

• c  Normal mood and affect.

c  Except abnormal for

 

5.    DATA and REVIEW

 

• Clinical lab tests:  c Ordered: __CBC   __CMP __U/A    __Lipids    __FOBT x3 days   __Mammogram

 __HbA1c    __PSA    __Free T4   __TSH   __B12 and Folate    __Others: ___

 __________________________________________________

                                 c Reviewed

 

• Radiology tests:   c Ordered: __Chest XR   __

                                      c Reviewed:

 

• Medicine CPT  tests:  c Ordered: __EKG    __Carotid Doppler __Others

                                    c Reviewed:

 

• Discussed the result of ________________ testing with performing physician Dr. ____________

 

• Obtaining:  c Old records from __________________________________________________

        c History from patient's ____________

 

••  Reviewing: c Old records provided additional/no additional information.

    c Additional history from _______________________provided additional/no additional information.

    c Consultation report from _____________________ provided additional/no additional information.

 

•• Independent visualization of: c EKG     c Specimen of ________  c Provided additional/no additional information

 

6. IMPRESSIONS/DIAGNOSES

 

 

 

7.  PLAN of CARE

 

c See the med (medication) list.        c See “DATA and REVIEW” above.    c  Stop smoking/drinking alcohol

 

c Dieting (low carb, low saturated fat, etc) was discussed.        c Regular exercise   c Put safety belt on

 

c Draft an advance directive         c Bring in all medications on every visit.            c  Others

 

 

c  Return to office in ________________      

-6-