WNWD NAD. Affect is normal and appropriate. Mucosa is pink and moist. Pharnx without erythema or injection. PERRLa. TMs and canals are normal bilaterally with normal light reflex and no erythema. Neck is supple without significant lympadenopathy or thyromegaly. Chest CTA with normal I:E. Heart is RRR, nL S1 and S2 without murmers, thrills, or rubs. Abdomen soft & non-tender. No HSM or masses appreciated. Extremities show no cyanosis, clubbing, or edema. Reflexes are normal and 2+ symmetrically of knees and achilles. Gait is WNL.
Timed up and go test 8 seconds
Reviewed Medicare assessment wellness questionnaire
SKIN EVAL - ABCDE
Asymmetry in 2 axes?
Border - irregular?
Colors - 2 differrent?
Diameter >6mm?
Evolution of lesion?all neg
oozing/crusting?
NEURO, FOOT EXAM all wnl
Beck scale is negative
Functional status assessment cognitive, sensory, (hearing vision, speech), and exercise all wnl
medication assessment including otc and herbal done
Advanced care planning - done
Comprehensive pain assessment - negative
just something I use for starters
