REVIEW OF SYSTEMS:
GENERAL: No fevers, sweats, shakes, chills or change in weight.
HEENT: No diplopia, amaurosis fugax, epistaxis or tinnitus.
CARDIOVASCULAR: As in HPI.
PULMONARY: No asthma, wheezing or night sweats.
GASTROINTESTINAL: Denies nausea, vomiting, diarrhea, abdominal pain. No hematochezia or hematemesis. Wife notes some anorexia.
GENITOURINARY: No dysuria, hematuria or bladder incontinence.
MUSCULOSKELETAL: No arthralgias, claudication, pain, paresthesias or leg edema.
ENDOCRINOLOGIC: Negative for excessive thirst, urination, heat or cold intolerance, diabetes or thyroid disease.
NEUROLOGIC: No history of convulsion, seizures, transient ischemic disease or cerebrovascular accident.
REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever. No chills. HEENT: No new headache, hearing or visual problems. He is hard of hearing. RESPIRATORY: No hemoptysis. No pleuritic chest discomfort. CARDIAC: No orthopnea or PND. No palpitations. GI: No reflux symptoms or blood in the stool. GU: No hematuria. SKIN: No new rashes. MUSCULOSKELETAL: No seizure abnormalities. NEUROLOGIC: As above. HEMATOLOGICAL/LYMPHATIC: No history of easy bleeding or bruising.
REVIEW OF SYSTEMS: The patient’s weight has been stable over the past year. Cardiovascular: He has had angina in the past but is stable at this time. Pulmonary: He has had shortness of breath but no history of pneumonia. GI symptoms: He does have a history of constipation at times. Urinary symptoms: He has frequent urination with urgency requiring medical management. He has a history of carcinoma of the prostate. He has microscopic hematuria. Musculoskeletal: He has arthritic complaints and back pain. Neurological: No specific complaints.
REVIEW OF SYSTEMS: GENERAL: Feels weak, fatigued. Appetite currently fair. No fevers, chills or night sweats. CARDIOVASCULAR: Denied chest pain, palpitations, orthopnea, or lower extremity edema. RESPIRATORY: Denied shortness of breath, cough, wheezing, sputum, sore throat. URINARY: Has had some episodes of urinary incontinence, but denies frequency, nocturia, dysuria, or hematuria. NEUROLOGIC: Numbness and tingling stocking/glove distribution lower and upper extremities. Has generalized weakness. ORTHOPEDIC: Uses a walker. No joint swelling. SKIN: No rashes or eruptions.
REVIEW OF SYSTEMS: The patient denies any fever, chills, or night sweats. She denies any recent loss of consciousness or trauma. No headaches, lightheadedness, or dizziness. No nausea, vomiting, diarrhea, or constipation. The patient does describe chest pain, but no palpitations, paroxysmal nocturnal dyspnea, or orthopnea. She does describe shortness of breath and dyspnea on exertion. She does describe a dry, nonproductive cough. No hemoptysis, hematemesis, hematuria, or bright red blood per rectum. She denies any abdominal pain, but does describe increased abdominal girth. She does describe significant edema of her lower extremities. No urinary complaints. She states she has moved her bowels on a fairly regular basis. She describes decreased appetite and decreased oral intake. She has been on Ensure for the past week. She describes increase in weight gain. The remainder of her review of systems is as noted in the history of present illness.
REVIEW OF SYSTEMS: The patient admits to fatigue; it has been a longstanding issue. She snores at night and does not awaken refreshed. She has a dog at home but denies any bug bites. She has had no rash, nausea, vomiting, fever, chills, diarrhea, constipation, melena, blood in her stool, headache, tooth pain, sputum production, chest pain or difficulty breathing. She feels safe at home. Her mood has been generally well controlled. She does exercise. She menstruates generally on a monthly basis, every other month being relatively heavy. She does not actively sunbathe. She does not sleep very well. She does get dental care.
REVIEW OF SYSTEMS: The patient states that she has had some headaches, but they have not been severe. Her vision has been blurred somewhat and is not been helped by glasses. She reports no difficulty in swallowing, but her stomach does tend to bloat easily. She has had chest pains in the past and is troubled frequently by shortness of breath on exertion and also at rest. She does not cough frequently, but as mentioned above, she does often in the morning expectorate a small amount of blood. She has not been troubled by routine abdominal pains but has had episodes of diarrhea in the past. She reports no difficulty with urination and has not seen any blood in the stool. She does get some stiffness in her joints and swelling in the feet but no skin rashes, and her weight has been stable.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies fever, chills, night sweats, tiredness, fatigue, malaise, anorexia, or weight loss.
CARDIOVASCULAR: No lower extremity edema. She has been ambulating extensively. She denies chest pain, palpitations or orthopnea.
RESPIRATORY: Denies shortness of breath, cough, wheezing, or sputum.
GENITOURINARY: Denies frequency, nocturia, dysuria, or hematuria.
GYNECOLOGIC: No abnormal bleeding.
HEMATOLOGIC: No abnormal prolonged bleeding or bruising.
MUSCULOSKELETAL: No joint swelling, stiffness, pain or myalgias.
INTEGUMENTARY: She has eczema on her hands.
NEUROLOGIC: Negative for any focal neurologic complaints.
PSYCHIATRIC: Frequent awakenings. Denies anxiety, panic or depression.
