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H&P Report, Physical Exam format help? - Mary triplet mommy

Posted: Aug 05, 2010

I added all the subheadings. I am sure of the subheading Neurology and eyes. Any suggestions? Anything else look incorrect? I am still new to this. Thanks for the help. PHYSICAL EXAMINATION VITAL SIGNS: Blood pressure is 112/80, weight is 155 pounds, and height is 5 foot 6 inches. GENERAL APPEARANCE: Well-developed, well-nourished. No apparent distress. HEART: Regular rate and rhythm. No murmurs, carotids. No bruits bilaterally. NEUROLOGY: Orientation and language are normal. EYES: Fundi with sharp disk bilaterally. Cranial nerves II full visual fields. Cranial nerves III, IV, VI extraocular movements are intact. No nystagmus. Pupils are equal, round, reactive to light. Patient walks to the right occasionally

I would change neurology - to NEUROLOGIC nm

[ In Reply To ..]
NM

Format help...sm - GT

[ In Reply To ..]
Just a few things different for me...
I would lose the comma on VITAL SIGNS after the word pounds, the "and" is sufficent. I would lose the hyphens in well developed and well nourished as they are only needed when used as an adjective, example "well-developed female." I would add an s to the word disk, especially if referring to both eyes. Otherwise, it looks fine. :)

Hope this helps... - no1joe

[ In Reply To ..]
VITAL SIGNS: Blood pressure is 112/80, weight is 155 pounds, and height is 5 foot 6 inches.

The commas are correct as you have them, or you can change it to:

VITAL SIGNS: Blood pressure is 112/80. Weight is 155 pounds, and height is 5 feet 6 inches.

I would make the following change to the Heart section also if you are at liberty to add/change headings as you see fit:

CARDIOVASCULAR: Regular rate and rhythm. No murmurs. Carotids no bruits bilaterally.

OR

HEART: Regular rate and rhythm. No murmurs.
NECK: Carotids no bruits bilaterally.

I don't have any of my reference materials available, but this is how the QAs would recommend at my company. Good luck!

Thank you! - Mary triplet mommy

[ In Reply To ..]
Thanks so much, appreciate all the feedback so much. I made the changes. =)

last sentence - maybe

[ In Reply To ..]
Patient LOOKS to the right occasionally. (last sentence)

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