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GENERAL MEDICAL HISTORY
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Patient Height
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Patient Weight
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Patient has a history of the following
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Past Medical History Freewrite
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Past Surgical History
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Past Surgical History Freewrite
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Drug Allergies
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Active Medications
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Females only
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Females only - # of children
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Ambulation
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GENERAL APPEARANCE
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Healthy-appearing
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Well-nourished
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Well-developed
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Level of Distress: (5 Being the Worst, 1 Being the Least Distress)
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Patient states that diet is maintained with mostly healthy, well-balanced meals.
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Patient has gained weight over the past 6 months.
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Patient has lost weight over the past 6 months.
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SOCIAL HISTORY
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Smoking
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If quit, how long ago; If active, PPD for years
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Alcohol
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If quit, how long ago; If active, drinks per day/week or month
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Illicit Drug Use
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REVIEW OF SYSTEMS
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CARDIOVASCULAR
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S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs
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GASTROINTESTINAL
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Patient states that diet is maintained with mostly healthy, well-balanced meals.
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MUSCULOSKELETAL
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Joint stability
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No tenderness to palpation in upper extremities
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INTEGUMENTARY
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Face
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Location of Abnormality
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NEUROLOGIC
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No Medical History/Injuries
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Awake, Alert, Oriented x3
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Attention and concentration within normal limits
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Communication ability within normal limits
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Patient c/o
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Location of Symptoms
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HEMATOLOGIC/LYMPHATIC
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Patient c/o
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RESPIRATORY
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Even and unlabored
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Abnormal
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Vascular Assessment
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Vascular Referral Yes / No
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PATIENT c/o
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RIGHT LEG
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LEFT LEG
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Additional Patient CC
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SEVERITY OF DISCOMFORT
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LOCATION
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Patient is significantly concerned due to
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Patient states symptoms started
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Diagnostic
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DIAGNOSTIC TESTS
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Diagnostic examinations performed
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Results: see attached LEVI report
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Ultrasound Report
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Ultrasound Report
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SEVERE FUNCTIONAL INCOMPETENCE OF
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RIGHT GSV
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RIGHT SSV
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LEFT GSV
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LEFT SSV
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Differential Diagnoses
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187.323 – Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity Chronic venous hypertension wi
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187.003- Postthrombotic syndrome without complications of bilateral lower extremity. Postthrombotic syndrome w/o complications o
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L81.0 Postinflammatory hyperpigmentation Hyperpigmentation (darkening) skin, after inflammation; Post-inflammatory hyperpigmenta
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Patient diagnosis codes
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Lab 1
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Lab 2
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