DATE: NAME: AGE: SEX: CC: HPI: Onset & progression character & severity precipitating, aggravating & relieving site and radiation PMH: illness, operations,hospital admissions DH: current meds, allergies, adverse rxn.s SH: job, hobbies, smoking, drinking, travel abroad, domestic problems, pets, heating type, smokers in family. ROS: GEN: No pain. No tiredness. No recent weight loss or gain. No sleep disturbances CV: No chest pain. No dyspnoea No orthopnoea. No palpitations RS: No cough. No sputum, No wheezing. No haemoptysis. GI: Good appetite. No dysphagia. No polydipsia. No heartburn. No flatulence. No recent change in bowel habits. No diarrhoea. No constipation GU: Waterworks OK? No frequency. No urgency. No haematuria. NS: No dizziness. No blackouts. No loss of balance. No muscle weakness, No parasthesias. No difficulty with vision. No hearing problems. Memory good. O/E: GEN: height,weight,hydration, consciousness, attitude, mood. No pallor, jaundice, or cyanosis. No finger clubbing. No lymphadenopathy. HEENT: Eyes Ears Nose throat & mouth thyroid trachea CHEST & LUNGS: breathing posture (kyphosis, scoliosis, lordosis) A-P diameter not increased symmetrical thoracic expansion. No wheezes or crackles audible. No decreased vocal fremitus. resonant to percussion in all lung zones. CVS: BP: Pulse: No Leg Oedema. No varicosities. JVP WNL. PMI not displaced. S1 & S2 heard w/o extrasystolic sounds or murmurs. Abdomen: No distention. Soft, nontender to palpation. Bowel sounds present. Liver nontender w/ edge palpable, soft, smooth about 2 cm below rt costal margin. kidneys, and spleen nonpalable. No masses palpable. Genitourinary: PR: no fissures. no skin tags, stool soft, Prostate palpable? Bladder nontender , not distended. NS: CN: #1:OK,#2:OK,#3:OK,#4:OK,#5:OK,#6:OK, #7:OK,#8:OK,#9:OK,#10:OK,#11:OK,#12:OK Gait: Speech: No tremors or dyskinesias. Muscle strength symmetrical, grade 5. Tendon & plantar reflexes intact and symmetrical. Impression: Plan: