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General
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Normal: Well appearing, no acute distress
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Eyes
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Normal: anicteric sclera, symmetric pupils
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Head/Ears/Mouth/Throat
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Head/Ears/Mouth/Throat: hearing grossly nl, EACs and TMs nl, good dentition, OP clear
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Neck
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Normal: supple, no thyromegaly, no nodules, no LAD
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Lungs
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Normal: CTA bilaterally, no wheeze
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CV
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Normal: RRR. No M/R/G, no edema
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ABD
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Normal: NABS, S/NT/ND, no masses, no HSM
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Rectal
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Deferred
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MSK
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Normal: grossly normal
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Neuro
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Normal: nl strength, nl gait
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Psych
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Normal: normal judgment, insight, mood, appropriate affect
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Skin
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Normal: no rashes, no ecchymoses, no suspicious lesions
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Procedure Description and Findings:
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Amount of Time Spent Counseling Patient and Coordinating Care, including diagnosis
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