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GENERAL:  No headaches or dizzy spells, Patient AOx3
HEENT:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIAC:  No chest pain, chest pressure or chest discomfort. No palpitations or edema
GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY:  No burning on urination, or dysuria
MUSCULOSKELETAL: She has a lot of arthritic complaints including stiffness, weakness. She has slow healing. The patient seems to be feeling well.
NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC:  No anemia, bleeding or bruising.
LYMPHATICS:  No enlarged nodes.
ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

 

Physical Exam

HEENT: Head is normocephalic and atraumatic. Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Nares appeared normal. Mouth is well hydrated and without lesions. Mucous membranes are moist. Posterior pharynx clear of any exudate or lesions.
NECK: Supple. No carotid bruits.  No lymphadenopathy or thyromegaly.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft, nontender, and nondistended.  Positive bowel sounds.  No hepatosplenomegaly was noted.
EXTREMITIES: Without any cyanosis, clubbing, rash, lesions or edema.
NEUROLOGIC: Cranial nerves II through XII are grossly intact.
SKIN: No ulceration or induration present.