Initial ROS & PE

Chief Complaint

[Insert chief complaint as stated by the patient.]

History of Present Illness

{ER_mode: Only generate content for ROS, vitals & PE sections that are explicitly discussed in the transcript of patient-doctor dialogues 1. Omit any system that is not mentioned or assessed 2. Do not add any additional systems or information not specified in this template 3. Each system assessment must start on a new line 4. Detail the symptom exactly the way the patient reported} [age] years old [gender] with a known history of [pertinent medical condition] presents with a [duration] history of [chief complaint]. Patient describes [pertinent positives and negatives]. Associated symptoms include [pertinent associated symptoms]. Denies [pertinent negatives].

Review of Systems

[List pertinent positives as mentioned as below, and list negative if mentioned. Otherwise, left blank] Constitutional: [Fever, chills, fatigue, lightheadedness.] HEENT/Eye: [Sore throat, dental problems, change in vision, eye discharge] Respiratory: [Shortness of breath, cough, wheezing, painful breathing] Cardiovascular: [Chest pain, palpitations] Gastrointestinal: [Nausea, vomiting, abdominal pain, diarrhea, bloody stools, black colored stool, constipation] Genitourinary: [Dysuria, urgency, frequency, hematuria, flank pain, genital pain] Musculoskeletal: [Back pain, new joint pain, swelling arms, swelling to legs, neck pain] Skin: [Rash, jaundice, new sores, itching] Neurological: [Sensory change, speech change, focal weakness, loss of consciousness, headaches, difficulty walking, confusion, vertigo] Psychiatric/Behavioral: [Depression, suicidal ideas, hallucinations, anxiety]

ROS Note

Other pertinent items as noted in the HPI All other systems reviewed and are negative

Physical Exam

General Appearance: [Describe level of distress, toxicity, secretions, and respiratory status. Otherwise, write "Patient appears to be in *** acute distress. Non-toxic appearing. Maintaining secretions. ***No signs of respiratory distress: ***no tachypnea, accessory muscle use, supraclavicular retractions, or abdominal breathing."] Head: [Document specific finding if mentioned. Otherwise, write "Atraumatic, normocephalic. No visible contusions. No scalp bogginess or step-off appreciated."] Ears: [Document specific finding if mentioned. Otherwise, write "External ears normal. Ear canals without visible drainage."] Eyes: [Document specific finding if mentioned. Otherwise, write "Sclera non-icteric. Pupils equal, round, and reactive to light. No relative afferent pupillary defect. Extraocular movements intact." ] Nose: [Document specific finding if mentioned. Otherwise, write " No external swelling or nasal drainage. No septal hematoma appreciated."] Mouth/Throat: [Document specific finding if mentioned. Otherwise, write "Mucous membranes moist. Uvula midline. No tonsillar exudates. No posterior pharyngeal swelling or mass appreciated."] Neck: [Document specific finding if mentioned. Otherwise, write "Supple. No meningismus/neck rigidity. No focal tenderness. No pain with gentle tracheal manipulation."] Chest wall: [Document specific finding if mentioned. Otherwise, write "Atraumatic. No chest wall tenderness."] Lungs: [Document specific finding if mentioned. Otherwise, write "No respiratory distress. Clear to auscultation bilaterally. No wheezes, rales, or rhonchi."] Heart: [Document specific finding if mentioned. Otherwise, write "***Regular rate and rhythm. Distal perfusion intact with capillary refill <2 seconds."] Abdomen: [Document specific finding if mentioned. Otherwise, write "On palpation, ***no tenderness noted and ***without peritoneal signs. Soft, non-distended. No rebound or guarding. No pulsatile mass appreciated."] Back: [No CVA tenderness, no midline tenderness, etc. Otherwise, write "On palpation, ***no tenderness noted and ***without peritoneal signs. Soft, non-distended. No rebound or guarding. No pulsatile mass appreciated."] Neuro: [Document specific finding if mentioned. Otherwise, write "Alert and conversant. Oriented x3. Moves all extremities spontaneously. Strength 5/5 upper and lower extremities. Sensation grossly intact. No gross non-focal neurologic deficit appreciated."] Extremities: [Document specific finding if mentioned. Otherwise, write "Atraumatic. No cyanosis. Radial pulses intact and symmetric bilaterally. Dorsalis pedis pulses intact and symmetric bilaterally. No ***pitting edema in lower extremities."] Psych: [Document specific finding if mentioned. Otherwise, write "Appropriate interaction. Normal affect."] Skin: [Document specific finding if mentioned. Otherwise, write "Warm and dry. No rash appreciated. No cyanosis or jaundice."]