ER visit with slit lamp exam

Chief Complaints: 
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HPI: 
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PMHx, PSHx: 
[textarea cols=80 rows=2 default="Nurses notes reviewed and confirmed."]

Soc Hx: 
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Medications/Allergies: 
[textarea cols=80 rows=1 default="Reviewed per triage note/Sorian"]


ROS:
[textarea cols=80 rows=1 default="GEN: no fever, no chills"]
[textarea cols=80 rows=1 default="EYES: no eye pain, no vision changes"]
[textarea cols=80 rows=1 default="HENT: no sore throat, no trouble swallowing."]
[textarea cols=80 rows=1 default="RESP: no cough"]
[textarea cols=80 rows=1 default="CV: no chest pain"]
[textarea cols=80 rows=1 default="GI: no abdominal pain"]
[textarea cols=80 rows=1 default="GU: no dysuria"]
[textarea cols=80 rows=1 default="MSK: no swelling in muscles or joints"]
[textarea cols=80 rows=1 default="NEURO: no weakness/numbness, no headache"]
[textarea cols=80 rows=1 default="SKIN: no rash, no easy bruising"]
[textarea cols=80 rows=1 default="PSYCH:"]


Physical Examination
[textarea cols=80 rows=1 default="VITALS: reviewed per triage note"]
[textarea cols=80 rows=1 default="GEN: non-toxic appearing, no acute distress."]
[textarea cols=80 rows=7 default="EYES: EOMI

Slit Lamp Exam: 

External: wnl ou
Lids and Lacrimation: wnl OU
Conjunctiva/Sclera: no injection, no chemosis 
Cornea: no ulcer under white light, no fluorescein uptake, no seidel sign
Anterior Chamber: no cells/flares, no hyphema 
Iris: flat, round OU
Lens: Dark
Vitreous:
IOP: 
"]
[textarea cols=80 rows=2 default="HENT: normocephalic, nares normal, oral mucosa moist"]
[textarea cols=80 rows=2 default="NECK: supple, FROM without pain"]
[textarea cols=80 rows=2 default="RESP: normal rate and effort, no accessory muscle use, symmetric chest wall rise"]
[textarea cols=80 rows=2 default="CV: "]
[textarea cols=80 rows=2 default="ABD/GI: "]
[textarea cols=80 rows=2 default="GU: "]
[textarea cols=80 rows=2 default="MSK: no apparent extremity deformity, moving all four extremities, adequately aligned spine. "]
[textarea cols=80 rows=2 default="NEURO: alert, oriented x 4, stable gait"]
[textarea cols=80 rows=2 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea cols=80 rows=1 default="PSYCH:"]


Laboratory and Radiology: 
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Assessment and Plan
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