REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies fever, chills or weight loss.
HEENT: The patient reports that he had an episode of blurry vision. He denies any congestions, sore throat or otalgia.
CARDIOVASCULAR AND PULMONARY: Chest pain as above. He denies palpitations, dyspnea on exertion, edema, syncope, aspiration. Shortness of breath as above. He denies cough, congestion, wheezing or sputum production.
GASTROINTESTINAL: He denies abdominal pain, hematemesis, melena, nausea, vomiting or diarrhea.
GENITOURINARY: He denies dysuria or urgency.
MUSCULOSKELETAL: The patient reports leg and joint pain as usual for him, unchanged from normal. He denies any joint swelling or warmth.
INTEGUMENTARY: He denies rash.
NEUROLOGIC: He denies headache. He denies dizziness, weakness, numbness or tingling in his extremities.
HEMATOLOGY/LYMPH: He denies any abnormal bleeding or bruising.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Denies fever or weight loss.
HEENT: Denies any visual changes or congestion. Reports intermittent sore throat over the last month. Denies any sinusitis.
CARDIOVASCULAR: Reports some chest discomfort associated with the chronic nausea and emesis that she has been having. Denies any palpitations, edema or syncope.
RESPIRATORY: Reports some intermittent shortness of breath relieved with her albuterol inhaler. Denies cough or wheezing.
GASTROINTESTINAL: Reports some abdominal cramping associated with her chronic emesis. Denies melena or hematemesis. Reports chronic daily nausea and emesis.
GENITOURINARY: Denies dysuria, urgency, discharge or bleeding currently.
MUSCULOSKELETAL: Denies any muscle or joint pain.
NEUROLOGIC: Denies headaches, dizziness, weakness, numbness or tingling in any of her extremities.
ENDOCRINE: Denies any polyuria, polydipsia or heat or cold intolerance.
PSYCHIATRIC: Reports having some stress at home and anxiety. Denies any depressive symptoms.
HEMATOLOGY: Denies any abnormal bleeding or bruising.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Denies fevers, weight change, headaches, visual changes, nausea or vomiting.
EYES: Denies cataract, glaucoma.
ENT: Denies nosebleeds, gum disease, has had his teeth extracted.
INTEGUMENTARY: Denies healing problems or rashes.
VASCULAR: Denies peripheral vascular disease, deep vein thrombosis, varicose veins.
NEUROLOGIC: Denies stroke, TIAs or seizures.
CARDIOVASCULAR: Has hypertension. Denies arrhythmia, myocardial infarction, congestive heart failure.
RESPIRATORY: Occasionally has wheezing, but denies the diagnosis of emphysema, bronchitis.
GASTROINTESTINAL: Denies peptic ulcer disease, liver disease, Hepatitis.
UROGENITAL: Denies any kidney disease, kidney failure.
MUSCULOSKELETAL: Denies gout or arthritis.
PSYCHIATRIC: Denies depression or anxiety.
ENDOCRINE: Denies diabetes or thyroid disease.
HEMATOLOGIC: Denies bleeding disorder, anemia.
IMMUNOLOGIC: Denies history of cancer, immunosuppression.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient notes that she has had a weight loss over the past one to two years of a significant amount.
HEENT: No history of trauma, vertigo or syncope. No history of photophobia, diplopia or color blindness. No history of nasal trauma, rhinitis or epistaxis. No history of tenderness or lesions of the oral cavity.
CARDIOVASCULAR: No history of palpitations, tachycardia, heart murmur, irregular rhythm, chest pain or discomfort.
RESPIRATORY: No history of asthma, shortness of breath, wheezing or pneumonia.
GASTROINTESTINAL: Please see the HPI.
GENITOURINARY: No history of dysuria, frequency or urgency.
MUSCULOSKELETAL: No history of weakness. No history of paresthesias, weakness, difficulty with coordination or balance.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative for fever, weight loss or night sweats.
HEAD AND NECK: Negative for visual changes, hearing changes, hoarseness, or sore throat. Negative for nasal problems. Positive for dry throat.
CARDIOVASCULAR: Positive for hypertension. Negative for coronary artery disease.
RESPIRATORY: Negative for shortness of breath, cough, asthma, or emphysema.
GASTROINTESTINAL: Negative for abdominal pain, nausea, vomiting, diarrhea, constipation, or hepatic disease.
GENITOURINARY: Positive for renal insufficiency, on dialysis.
HEMATOLOGIC: Denies anemia.
ALLERGIC/IMMUNOLOGIC: Positive for multiple myeloma.
INFECTIOUS: Denies infectious disease processes.
ENDOCRINOLOGY: Negative for diabetes mellitus. Negative for thyroid dysfunction.
MUSCULOSKELETAL: Positive for back pain with multiple compression fractures and sacral fracture noted as well worrisome for metastatic disease. The patient is receiving radiation therapy currently.
NEUROLOGIC: Denies seizures, strokes, or headaches.
PSYCHIATRIC: Denies anxiety or depression.
DERMATOLOGIC: Negative for skin condition.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever or weight loss. The patient has mild fatigue.
HEENT: Eyes: He uses glasses. No blurry vision or loss of vision. ENT: No loss of hearing, sinus drainage, difficulty swallowing.
CARDIOVASCULAR: Chest pain as noted in the history of present illness. No heart attack or palpitations.
RESPIRATORY: No shortness of breath, pneumonia, or pulmonary disease.
GASTROINTESTINAL: Reflux disease. No diarrhea or constipation.
GENITOURINARY: No dysuria, frequency, or kidney problems.
MUSCULOSKELETAL: No joint pain, arthritis, or muscle pain.
SKIN: No rashes or itching.
NEUROLOGIC: No stroke, seizure, or nerve damage.
PSYCHIATRIC: Depression. No mood swings or other mental disorder.
ENDOCRINE: Diabetes. No thyroid disorders.
HEMATOLOGIC: Anemia. No thrombocytopenia or bleeding disorders.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient states he is in fairly good health, with the exception of his vascular problems. No recent fever, chills, or severe weight changes. He states he has gained some weight recently.
INTEGUMENTARY: No complaints of problems with skin. No jaundice, rash, itching, lumps, or cellulitis. The only problem was the gangrene in his right leg.
HEENT: Ears: There is no hearing loss or tinnitus. Eyes: No visual changes or diplopia. Nose: No stuffiness, drainage, itching, or hay fever. No epistaxis. Throat and Mouth: No hoarseness, dysphagia, bleeding from his gums, leukoplakia, or sore throat.
NECK: No goiter, masses, nodules, or adenopathy.
CARDIOVASCULAR: He has hypertension. No edema.
RESPIRATORY: Positive for cough. He states he does cough up some sputum at times. It is clear yellow. No complaints of shortness of breath. No orthopnea or dyspnea.
GASTROINTESTINAL: No heartburn, dysphagia, decrease in appetite, indigestion, or hematemesis.
GENITOURINARY: He does not have any dysuria, polyuria, frequency, or incontinence.
PERIPHERAL VASCULAR: He does have a history of peripheral vascular disease. He has an amputation on the left and now on the right.
