Template for the Medical Documentation write-up by the stude…
Questions
Templаte fоr the Medicаl Dоcumentаtiоn write-up by the students: CC: HPI: Allergies: Medications: Health Maintenance: Surgeries: Hospitalizations: Ongoing Medical Problems: Substance Use: Smoking: ETOH: Recreational drugs: Social Hx: Living situation: Occupation: Sexual hx: Diet: Exercise: Family Hx: ROS: Constitutional: Integumentary: Eyes: Ear, nose, mouth and throat: Respiratory: Cardiovascular: Gastrointestinal: Genitourinary: Musculoskeletal: Neurologic: Hematologic/Lymphatic: Endocrine: Psychiatric: Physical Exam: For the Physical Exam: VS: Cranial nerve exam: Eyes: Pupillary reflexes, EOM, Accommodation, and visual fields: Ophthalmoscope exam: Carotid exam for pulses and bruits: Thyroid Chest Heart Abdomen Pulses: Extremities: Skin: Neurologic and Musculoskeletal exam: Sensory testing: Strength testing: Cerebellar exam: Rapid alternating movement (Patty cake maneuver), Finger to nose Heel to shin Regular gait and tandem gait Romberg test: Reflexes: Biceps Patellar and Achilles Babinski MOCA exam: (1) Orientation: (2) Attention: (3) Immediate Memory: (4) Delayed Recall: MENTAL STATUS EXAM: Differential Diagnoses and Supporting Evidence: You are only required to list 4 diagnoses, but may list up to 8 Stroke may not be used as a diagnosis, but may be used as supporting evidence. #1: Supporting Evidence by History: Supporting evidence on Physical Exam: #2: Supporting Evidence by History: Supporting evidence on Physical Exam: #3: Supporting Evidence by History: Supporting evidence on Physical Exam: #4: Supporting Evidence by History: Supporting evidence on Physical Exam: #5: Supporting Evidence by History: Supporting evidence on Physical Exam: #6: Supporting Evidence by History: Supporting evidence on Physical Exam: #7: Supporting Evidence by History: Supporting evidence on Physical Exam: #8: Supporting Evidence by History: Supporting evidence on Physical Exam: