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Cary Carpenter, M.D. Choctaw Family Medicine Michael H. Terry, M.D. - page 1 / 2

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Cary Carpenter, M.D. Choctaw Family Medicine Michael H. Terry, M.D.

Adult Established Patient

Name ___________________________________Date ___________________________________

Chief Complaint ___________________________

_____________________________________________________________________________________________________________________

Started ________________________________

_______________________________________

_Review PMH /Social History

Changes to PMH/Social History _______________________

______________________________________________________________________________________________

Review of Systems

GeneralGI

_Fever ___________________Nausea __________________

_Chills ___________________Vomiting _________________

_Weakness ________________Diarrhea _________________

_Weight Loss ______________Abd. Pain ________________

HEENTGU

_Sore Throat ______________Dysuria _________________

_Sinus Drainage ____________Frequency _______________

_Ear ache/Drainage _________Hematuria _______________

CARDIACNEUROLOGY

_Chest Pain ________________Headaches _______________

_Palpitations _______________Vertigo __________________

RESPIRATORYSKIN

_Cough ___________________Rashes __________________

_SOB ____________________Lesions __________________

Other ________________________________________________

_____________________________________________________

Physical Exam

Vital Signs

BP ______________ Pulse ___________ T _____________

Wt ____________ Ht ____________ LMP _____________

HEENT

_Nml ENT Inspection_Conj. Injection ___________________

_Eyes nml_TM erythema/dull _________________

_TM’s nml_Tonsilar erythema/exudates _________

_Pharynx nml_Purulent nasal drng ________________

_Nares nml_Fundiscopic abnormality _____________

_Fundi nml________________________________

NECK

_Nml inspection_Thyromegaly/nodules ______________

_No Bruits/JVD_Lymphandenopathy L/R _____________

_Bruits/JVD ______________________

RESPIRATORY

_No Resp. distress_Rales __________________________

_Nml Breath sounds_Rhonchi ________________________

_No tenderness_Wheezing _______________________

_Chest Wall Tenderness _____________ CARDIAC

_RRR_Irreg. irreg. rhythm _______________

_No Murmur_Tachy/Brady _____________________

_No gallop_Murmur grade ___/6 sys/dys_________

ABDOMEN

_Non-tender_Tenderness _____________________

_No HSM_Rebound _______________________

_No Masses_Mass _______________________

_Hepato/Splenomegaly ______________

GU/RECTAL

_Nml External Gent._Vesicles/ulcerations _______________

_No masses_Vaginal/Penile Discharge ____________

_Nml Spec. Exam_CMT ___________________________

_Nml Bimanual_Adenexal Mass ___________________

_Heme-neg. Stool_Testicular Mass/Tenderness _________

_Nml Prostate_Black/Bloody stool _________________

_Guaiac positive ___________________

_Prostate enlargement/mass __________

BREAST

_NML inspection_Mass ___________________________

_No masses_Nipple discharge __________________

BACK

_Non-tender_Tender in PS muscles _______________

_Nml ROM_Spasms with ROM _________________

_SLR’s Positive R/L _________________

EXTREMITIES

_Nml ROM_Decreased ROM __________________

_Non-tender_Joint pain/edema__________________

_No Edema_Weakness _______________________

_NVI Distally_Joint laxity ______________________

_Deformity _______________________

________________________________

NEURO

_Alert & Oriented_Disoriented ______________________

_CN’s normal_Weakness _______________________

_Sensory loss _____________________

________________________________

SKIN

_No Rash_Rash ___________________________

_No Lesions_Lesion __________________________

Other/Lab/X-ray results _______________________

______________________________________________________________________________________

Clinical Impression

____________________________________________________________________________________________________________________________________________________________

Treatment

____________________________________________________________________________________________________________________________________________________________

Signature

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