ELECTROPHYSIOLOGY CONSULT
DATE:
CC:
HPI:
PAST MEDICAL HISTORY:
MEDICATIONS:
ALLERGIES: Patient has answered NKA
FAMILY HISTORY:
SCD:
SOCIAL HISTORY:
TOB:
EToH:
Drugs:
REVIEW OF SYSTEMS:
GENERAL: Denies fever/chills, change in weight
HEAD: Denies dizziness/vertigo, syncope, head trauma.
EYES: Denies any recent change in vision
EAR: Denies change in hearing
NOSE: Denies epistaxis, congestion, rhinorrhea, sinusitis.
MOUTH/THROAT: Denies ulcers
NECK: Denies any pain, stiffness, swelling, masses, thyroid problems.
RESPIRATORY: Denies worsened cough, wheezing/asthma, productive sputum
CARDIO: Denies any chest pain, orthopnea, PND, palpitations, history of
murmurs, edema, claudication
GI: Denies anorexia, weight loss, hematemesis,abdominal pain, change in
bowel habits, hematochezia, bloody stool, melena.
GU: Denies dysuria
MUSCULOSKELETAL: Denies joint pain, stiffness, swelling, heat, deformity,
back pain, bone pain, or myalgia.
SKIN: Denies changes.
NEURO: Denies paralysis, seizures, tremors.
PSYCH: Denies change in mentation or behavior.
HEME/LYMPH: Denies anemia, easy bruising, bleeding or lymphadenopathy.
PHYSICAL EXAM:
General: Normal appearance, normally groomed, normal developed male.
The patient was alert and oriented x 3.
Head: The head exam revealed the patient to be normocephalic, atraumatic.
Eyes: The eye exam reviewed that extra-ocular movements were intact and that
the conjunctivae and lids were grossly normal. PEERLA.
ENT: The oral mucosa was normal in appearance with no obvious cyanosis or
pallor noted. Oropharynx is without lesions. The nares are patent. Dentition
is fair.
Neck: Supple. Trachea is midline. No JVD. Carotid upstrokes were brisk.
No bruits. No thyromegaly or masses.
Chest: Lungs were clear to auscultation bilaterally. Breathing is unlabored.
Normal respiratory excursion.
CV: Normal rate with a regular rhythm. S1 was normal, S2 was normal.
Abd: Bowel sounds were present. Soft. Non-tender, non-distended.
Ext: No clubbing, cyanosis, or edema noted. Pulses were palpable, including
dorsalis pedis. Feet was not examined as part of this exam.
Neuro: No focal neuro deficits noted. Appropriate muscle strength and tone.
Psychiatric: Normal and appropriate affect.
IMPRESSION:
Total visit time 55 minutes
Elements contributing to total time include:
-Time personally spent with the patient
-Obtaining and/or reviewing separately obtained history
-Performing a medically appropriate examination and or evaluation
-Counseling and educating the patient/family caregiver
-Ordering medications, tests, or procedure
-Referring to and communicating with other healthcare professionals
-Documenting clinical information in the electronic or other health
record
-Independently interpreting results and communicating results to the
patient/family/caregiver
-Care coordination