Here is a detail about All Review of Systems to ask your patients when taking a complete History
Physical Exam findings with abbreviation
HPI : Cheif complaints
ROS : headache , fever , nausea / vomitting , travel , diarrhea , constipation , urination ,weight , appetite , diet , excercise , chest pain SOB,racing of heart ,rash , edema , pain in joints , infection , dizziness if yes vision problem , sleep problem
ALLERGIES : none
MEDICATIONS :
PMH :
(h) ospitalized ?
(i) ll contacts
(t) rauma ?
PSH :
FH :
SH :
PHYSICAL EXAM:
HEENT: NC/AT
NECK: WNL
RS: Breath sounds are normal
BACK:
CVS: S1/S2 normal
ABDOMEN:
EXTERMITIES:
NEURO:
MINI MENTAL EXAM
Diagnosis 3 with History and physical findings
Work plan : ...?
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