REVIEW OF SYSTEMS: Negative for headache, syncope, diplopia, dysarthria, dysphonia, dysphagia, hemiparesis, paresthesia. No fever, chills, night sweats. No cough, shortness of breath, hemoptysis. No abdominal pain, nausea, vomiting, melena, hematemesis, gross rectal bleeding, dysuria, frequency, hematuria, claudication, pedal edema, arthralgia or redness other than the left hand.
REVIEW OF SYSTEMS: On review of systems, the patient denies recent URI, fever, chills, weight loss or night sweats. No headache, visual symptoms, stiff neck. She had no associated neck, arm, jaw pain or pressure today. She does have chronic back and body aches, which are diffuse and varying in site from day to day. She denies significant abdominal pain, change in bowel habits, black tarry stools, bright red blood per rectum. No urinary symptoms. No swelling of her hand, feet or face. No neurologic symptoms. No rash. No lymphadenopathy. A 14-point review of systems is otherwise negative. The patient is completely asymptomatic at this time.
REVIEW OF SYSTEMS: No history of heart or valve problems previously. No orthopnea or PND. Denies headache, dizziness or feeling faint. No visual disturbances, ear, nose of throat complaints, neck pain, stiffness, cough, sputum production, diabetes, hypertension, dyslipidemia, abdominal pain, nausea, vomiting, diarrhea, rashes, vesicular eruptions, lesions, numbness, tingling or paralysis.
REVIEW OF SYSTEMS: The patient denies weight change, fatigue, weakness, fever, chills, night sweats. The patient denies itching, rashes, sores and bruises. The patient denies headache, nausea, vomiting, visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck: No complaints. The patient denies shortness of breath, wheeze, cough, and hemoptysis. The patient denies chest pain and palpitation. The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation, or diarrhea. The patient has normal urination. The patient has amenorrhea. The patient denies muscle weakness. The patient denies pain or joint stiffness. The patient denies restriction of range of motion. The patient has full range of motion of the upper and lower extremities.
REVIEW OF SYSTEMS: No chest pain, palpitations, shortness of breath, nausea, vomiting, abdominal pain, lightheadedness, dizziness, sudden changes in vision, speech, gait, swallowing, memory, numbness, tingling, weakness, orthopnea, PND, lower extremity edema, myalgias, arthralgias.
REVIEW OF SYSTEMS: He has had no frank gross hematemesis, no hematochezia, no melena or black tarry stools. No dizziness, feeling faint, visual disturbances, ear, nose or throat complaint, cough, shortness of breath, sputum production, chest pain, periumbilical pain, right lower quadrant pain, right upper quadrant pain, postprandial discomfort, rashes, skin breakdown, numbness, tingling or paralysis.
REVIEW OF SYSTEMS: The patient denies weight change, fatigue, weakness, fever, chills, night sweats. The patient denies itching, rashes, sores and bruises. The patient denies headache, nausea, vomiting, visual changes. Eyes, ears, nose, sinuses, mouth, throat, neck, no complaints. The patient denies shortness of breath, wheeze, cough, and hemoptysis. The patient denies chest pain and palpitation. The patient has normal appetite. Denies nausea, vomiting, dysphagia, abdominal pain, constipation or diarrhea. The patient complains of frequent urination. No blood in urine. No urine retention. No pain during urination. The patient usually goes to the bathroom during the night two to three times, during the daytime three to four times. The patient denies muscle weakness. The patient denies pain, joint stiffness. The patient complains of low back pain radiating to the left lower extremity with numbness of the left lower extremity and episodes of weakness of the left lower extremity. The patient has restriction of range of motion at the lumbosacral spine on flexion and extension. The patient has full range of motion of the upper and lower extremities.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: There is no history of fever, weight loss or cough.
CENTRAL NERVOUS SYSTEM: No history of vision changes, seizure or weakness.
ENT: No history of congestion, postnasal drip, sore throat or hearing changes.
RESPIRATORY: No history of shortness of breath, wheezing or chest pain.
CARDIOVASCULAR: No history of chest palpitations or arrhythmias.
GASTROINTESTINAL: No history of nausea, vomiting, diarrhea or abdominal pain.
GENITOURINARY: No history of dysuria, frequency or vaginal discharge.
MUSCULOSKELETAL: Positive for ankle pain, joint pain, joint edema as well as right lower extremity edema with some tenderness in the calf area. The patient indicates that her pain is approximately 7/10.
REVIEW OF SYSTEMS: The patient denies fevers, chills, sweats, headaches, dizziness, feeling faint, tinnitus, vertigo, hearing loss, nasal discharge, sore throat, trouble swallowing, neck pain or stiffness. No tunnel vision, blurred vision, loss of vision, amaurosis, seizure activity, neck pain or stiffness. No cough, shortness of breath, chest pain on exertion, asthma, hemoptysis. No history of pulmonary embolisms or pulmonary conditions. She denies retrosternal chest pain, radiating pain, abdominal pain, tooth pain, arm pain, chest pain exertion, CHF, cardiomyopathy, diabetes, hypertension or dyslipidemia. No generalized abdominal pain. No nausea, vomiting, diarrhea, heartburn, reflux, gallstones, kidney stones, hematuria, dysuria, urgency, frequency, hematuria, rectal discharge or bleeding. No rashes, skin breakdown, numbness, tingling with paralysis or shingles.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: She denies any recent weight changes, fevers or night sweats.
DERMATOLOGIC: She denies any rashes.
HEENT: Eyes: She has had no changes in her vision. No eye pain. No discharge. ENT: She had no hearing changes, no throat pain, no sinus difficulties. No hoarseness.
CARDIOVASCULAR: She denies any chest pain or abnormal heart beats, or any swelling in her ankles or feet.
RESPIRATORY: No wheezing or coughing.
GASTROINTESTINAL: As noted above in history of present illness.
GENITOURINARY: She denies any urinary urgency, frequency or burning, and there has been no blood in her urine. She has no flank pain. She has also had no vaginal discharge or bleeding.
MUSCULOSKELETAL: She notes full range of motion of all her joints without pain or swelling.
ENDOCRINE: She denies any heat or cold intolerance or excessive thirst or urination.
NEUROLOGICAL: Currently, no headache. She has no vision changes, dizziness or fainting. No numbness or tingling.
PSYCHIATRIC: As noted above in past medical history.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient has had no recent weight changes, fevers, night sweats or fatigue.
DERMATOLOGIC: She denies any lesions or rashes.
HEENT: Eyes: She has had no change in vision as mentioned in the history of present illness. ENT: No complaints other than the tooth injury she has at present.
CARDIOVASCULAR: She has had no chest pain, abnormal heart beats or shortness of breath.
RESPIRATORY: No wheezing or coughing.
GASTROINTESTINAL: She has had no nausea or vomiting and no abdominal pain or diarrhea.
GENITOURINARY: She has had no frequency, burning or flank pain and no vaginal symptoms.
MUSCULOSKELETAL: As noted in history of present illness.
ENDOCRINE: She has had no cold or heat intolerance or excessive thirst or urination.
HEMATOLOGIC: She has had no excessive bleeding or clotting.
NEUROLOGIC: As mentioned above, she has had no headaches, vision changes, dizziness, fainting or numbness, tingling or weakness from her accident.
REVIEW OF SYSTEMS: No nasal sinus congestion. No history of nasal trauma. No history of hypothyroidism. She is a prediabetic. She has no history of lung disease. She never smoked. No history of coronary artery disease, congestive heart failure or cardiac dysrhythmia. Gastrointestinal review of systems is negative. She is status post cholecystectomy. History of pancreatitis. She has a weight gain as noted above. Chronic fatigue and sleepiness and history of depression as noted above. Otherwise, review of systems is negative.
REVIEW OF SYSTEMS: The patient has had intermittent fevers. Eye history is negative for photophobia or diplopia. She has had a bifrontal headache. She has not had any nuchal rigidity. She has no focal neurologic symptomatology. She has not had any sore throat or otalgia. She has not had any cough or productive sputum. She has had some mild lower abdominal cramping and flank pain. She had a recent diagnosis of UTI. Today, she developed vomiting. She has had no diarrhea. She has had myalgias. She has had no skin rashes. She has had no obtundation or neurologic changes.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies fevers, chills, sweats and body ache.
HEENT: Denies headache, blurry vision, eye pain, tinnitus, vertigo, gingival bleeding, sore throat, neck or thyroid masses.
RESPIRATORY: Denies cough, sputum, hemoptysis.
CARDIAC: Denies chest pain, pressure, palpitations, irregular heartbeats. Denies lower extremity edema.
GASTROINTESTINAL: Denies abdominal pain, changes in bowel habits or any bleeding on toilet paper.
GENITOURINARY: Denies dysuria, hematuria, nocturia or frequency. Occasional drips of urinary incontinence. She is a postmenopausal woman who has had no postmenopausal bleeding.
NEUROLOGIC: Denies headaches, dizziness, syncope.
MUSCULOSKELETAL: Positive for arthritis with joint stiffness in the morning. Denies muscle weakness. Limitation in range of motion.
VASCULAR: Denies claudication and cramping.
ENDOCRINOLOGY: Denies heat or cold intolerance. Positive for diabetes.
HEMATOLOGY: Denies easy bleeding or blood transfusion.
DERMATOLOGY: Denies changes in moles or pigmentation changes.
PSYCHIATRY: Denies depression, agitation or anxiety.
REVIEW OF SYSTEMS: The patient reports that she feels good. No recent changes. Denies recent fever. She did report that she has had recent vision difficulty and knows that she needs to see an ophthalmologist. Denies eye pain, inflammation, discharge, lesions. Reports no difficulty with hearing. No earaches or recent infections. Denies mouth pain. Denies bleeding of the gums. Denies sores and lesions in the mouth. Denies trouble swallowing or hoarseness. No neck pain. Denies limitation of motion. Denies lumps or swollen glands. Reports no changes in her breasts. Reports no nipple discharge, rash or swelling. No chest pain with breathing. Denies wheezing. Denies shortness of breath. Denies chest pain, cyanosis, fatigue, or trouble breathing on exertion. No history of heart murmur, hypertension, CAD, or anemia. Denies numbness or tingling. Denies swelling of the legs. The patient reports having a good appetite with no recent changes. Denies heartburn or indigestion or pain or nausea or vomiting. Denies difficulty with urination, urgency or frequency. Denies flank pain.
REVIEW OF SYSTEMS: No fevers, chills, sweats, headaches, visual disturbances, ear, nose or throat complaints, cough, shortness of breath, sputum production, retrosternal chest pain, radiating pain, jaw pain, tooth pain, arm pain, hypertension, diabetes, dyslipidemia, heart or valve problems, heart attacks, strokes, seizures, thyroid illness, cancer. He had no periumbilical pain, abdominal pain, nausea, vomiting or diarrhea, constipation, hematochezia, melena, dark tarry stools, rashes, skin breakdown, numbness, tingling or paralysis. He denies any history of chronic kidney disease, peptic ulcer disease, gastritis, heartburn or reflux.
