General Template

HISTORY:

Presents for ‍ for ‍ ‍hoursdays

Onset: ‍gradualsuddentraumatic, following ‍

Location: ‍

Radiation: ‍none ‍

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Type: ‍crampingburning

Pattern: ‍constantintermittent, worse during the ‍day

Episode duration: ‍ ‍secminhoursdaysweeksmonths

Worsening factors: ‍none ‍

Treatments tried: ‍none, ‍effectiveineffective

‍no symptoms



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍



PLAN:

-

-

- Follow-up in ‍ ‍daysweeksmonths

- Return if symptoms worsen or new symptoms develop