Patient seen at: Patient_seen.
>>>> HPI:
>>>> History_not_limited.
>>>> ROS:
(_)In addition to the systems reviewed below, all other systems
reviewed are negative except for those included in above history.
GENERAL(System): (-)fever, (_)fatigue
SKIN(System): (-)rash
EYES(System): (-)visual change
ENT(System): (-)sore throat (_)earache
RESPIRATORY(System): (-)cough , (-)SOB
CARDIOVASCULAR(System): (-)chest_pain, (_)palpitations, (_)DOE
GASTROINTESTINAL(System): (-)abdominal pain, (-)nausea, (-)vomiting, (_)diarrhea, (_)constipation
GENITOURINARY(System): (-)dysuria, (-)hematuria, (_)discharge
MUSCULOSKELETAL(System): (-)arthralgias, (-)myalgias, (_)back pain
NEUROLOGICAL(System): (-)headache, (_)weakness, (_)numbness, (_)dizzy, (_)syncope
PSYCHIATRIC(System): (_)depression
>>>> PMH:
>>>> PSH:
>>>> FH: HTN
>>>> SOCIAL_HISTORY:
Alcohol_History:
Smoking_History:
Substance_Abuse_History:
Domicile_History: Lives at home
>>>> PHYSICAL_EXAM:
GENERAL_APPEARANCE: NAD, no stridor
EYES: conjunctiva clear
ENT\HEAD\NECK:
HEAD: atraumatic appearance
EARS:
NOSE: no_nasal_discharge
THROAT: uvula midline, no pharyngeal exudates or erythema, no drooling
MOUTH: moist mucous membranes
NECK:
CARDIOVASCULAR:
HEART: RRR, S1/S2, no M/R/G
RESPIRATORY:
LUNGS: CTAB/L,
good air movement, no wheeze, no rales, no accessory muscle use
GASTROINTESTIONAL:
ABDOMEN: soft, non-ttp, non-distended, no organomegaly
MUSCULOSKELETAL:
EXTREMITIES: distal NVI x 4 ext, no edema
BACK:
CHEST_WALL:
SKIN: warm
NEURO: GCS 15, gait steady, motor 5/5 x 4 ext, SILT x 4 ext, CN 2-12 intact
HEMATOLOGY: (-)bruising
>>>> DIFFERENTIAL_Dx: