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  • On Service Note

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    林法菲
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    This medical document summarizes a patient's examination under anesthesia. The patient's vital signs and physical exam findings are noted, including normal temperature, blood pressure, and assessments of the head, neck, chest, heart, abdomen, and extremities. An impression is made but not stated. The plan is not detailed. The record is signed by a registered nurse.

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    This medical document summarizes a patient's examination under anesthesia. The patient's vital signs and physical exam findings are noted, including normal temperature, blood pressure, and assessments of the head, neck, chest, heart, abdomen, and extremities. An impression is made but not stated. The plan is not detailed. The record is signed by a registered nurse.

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    344 views1 page

    On Service Note

    Uploaded by

    林法菲
    This medical document summarizes a patient's examination under anesthesia. The patient's vital signs and physical exam findings are noted, including normal temperature, blood pressure, and assessments of the head, neck, chest, heart, abdomen, and extremities. An impression is made but not stated. The plan is not detailed. The record is signed by a registered nurse.

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    © All Rights Reserved
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    On Service Note

    <Present Illness>

    <Physical examination>
    Consciousness: under the anesthesia
    Vital sign TPR: ℃, BP: mmHg
    Conjunctiva: not pale, Sclera: anicteric
    Head and Neck: JVE (-), goiter (-)
    Chest: symmetrical expansion, breathing sound: crackle
    Heart: regular heart beat, no murmur
    Abdomen: mild soft, bowel sound: hypoactive
    Extremities: extremity warm
    <Impression>

    <Plan>

    Recorded by RN /VS

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