Sample Report

physical examination vital signs: pulse 102, respiratory rate 22, temperature 96.5�f, blood pressure 154/64, pulse oximetry 98% on room air. general examination: sitting quietly on the cart, alert, awake, and appropriate. skin examination: skin examination showed no petechiae, no abnormal bruising except for a quarter-to-silver-dollar-size bruise in the right upper chest wall region that was somewhat yellowish. no other rash. neck: neck was supple. no jvd or adenopathy appreciated. no axillary or inguinal adenopathy appreciated. oropharyngeal examination: clear. had normal mucous membranes and no mucus icteric changes. eyes: eyes were normal without icteric changes. extremities: extremities all appeared atraumatic, showed full range of motion. no abnormal swelling or joint pain or tenderness. chest: clear to auscultation. cardiac: regular rate and rhythm without murmurs, rubs, or gallops. abdomen: soft and nontender. no hepatosplenomegaly appreciated. neurological examination: moving all four extremities nonfocally with good strength. mental status examination: awake and oriented with normal mood and affect. sample medical report diagnoses 1. cerebrovascular accident. 2. schizophrenia. 3. recurrent transient ischemic attacks. procedures 1. echocardiogram. 2. holter monitor. history of present illness this is a 46-year-old right-handed woman with a history of hypertension, schizophrenia, and an ovarian tumor resected surgically and with radiotherapy treatment. she presented to the emergency room with a 4-hour history of difficulty talking, along with numbness and weakness on the right side. she was in her usual state of health until early the morning of admission when she woke up and noted numbness on her right side. her numbness was associated with weakness as well as difficulty speaking, with no associated headache, chest pain, fever, chills, double vision, difficulty swallowing or palpitations. she reported having a similar incident about one month prior to admission when she was seen in the emergency room, but at that time her symptoms resolved while in the er. ct scan at that time showed bilateral basal ganglion infarcts. carotid studies then showed minimal plaque, right greater than left, with no hemodynamic stenosis. at that time she was sent home on aspirin one time daily, which she has been taking except for the day prior to admission when she missed her dose. physical examination vital signs: temperature 98.6, blood pressure 164/100 in both arms. heent: examination is clear. neck: there is a mild right bruit. lungs: lungs are clear. abdomen: abdomen is obese with a surgical scar. bowel sounds are present. neurologic: she is alert and oriented x3. she has difficulty with speech, mostly lingual sounds. no aphasic symptoms and normal flow, normal rate, and normal content. no shortness of breath noted. cranial nerves showed right fundi with sharp disks. pupils are equal and reactive to light. face was symmetric. eye

closure, puffed cheeks, and smile are symmetric. her gag is present bilaterally, left greater than right. reflexes are 2+ with downgoing toes. lab data the laboratory data was unremarkable. ecg showed normal sinus rhythm. hospital course the patient was admitted to the neurology service with concern for an embolic versus ischemic event in the face of aspirin therapy. as an inpatient she had an echocardiogram, which was reported to show mild, concentric, left ventricular hypertrophy, no mitral regurgitation, and no aortic regurgitation. carotids were not repeated since she had a carotid study one month prior to admission that showed an occlusion of her carotids. rpr was nonreactive. blood pressure remained under control during the hospitalization. her psychiatric symptoms were stable during this time. she was seen by physical therapy and occupational therapy who helped her with ambulation. by discharge she was making good progress, ambulating, and using her arms, although she remained with weakness on the right more than the left. she was discharged in good health. discharge instructions her medications are to include nortriptyline 25 mg p.o., aspirin, and benadryl 50 mg p.o. nightly. diet: she is to be on a low-cholesterol diet. follow up with physical therapy and occupational therapy as scheduled.