Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
Denies cough, wheezing, dyspnea at this time
Eyes Corrective lenses
Gastrointestinal Denies abdominal pain,
...
Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
Denies cough, wheezing, dyspnea at this time
Eyes Corrective lenses
Gastrointestinal Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ears Denies ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological Denies urgency, frequency burning, change in color of urine, vaginal discharge or STDS. Hysterectomy 5 years ago. Last mammography 1 years ago. G2, P2, A0
Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain
Musculoskeletal Localized symptoms in hand joints: pain, tender, swollen, and decrease range of motion.
Breast SBE every month, denies lumps, bumps or changes
Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance
Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
OBJECTIVE Weight: 139 BMI: 23.9 Temp: 98.2 BP: 127/79 Height: 5’4 Pulse: 84 Resp: 16 General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Skin Skin is white, warm, dry, clean and intact. No rashes.
HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized.
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