CHIEF COMPLAINT: [text]
HISTORY OF PRESENT ILLNESS:
[textarea][/textarea]
PAST MEDICAL HISTORY:
[textarea][/textarea]
REVIEW OF SYSTEMS:
[textarea]As above in HPI.
Other pertinent constitutional symptoms, HEENT symptoms, cardiac symptoms, respiratory symptoms, gastrointestinal symptoms reviewed and negative[/textarea]
ALLERGIES:
[text]
MEDICATIONS:
[textarea][/textarea]
PHYSICAL EXAM:
[textarea]VITALS:
GENERAL: alert, no distress
HEENT: oropharynx clear
RESPIRATORY: Clear to auscultation bilaterally.
CV: Regular rate and rhythm.
ABDOMEN: Bowel sounds normal. soft.
SKIN: No rashes
NEURO: Strength 5/5 at upper and lower extremities. Gait normal.
[/textarea]
ASSESSMENT/PLAN:
[textarea]
orders reviewed
appropriate follow up discussed - before last refill, sooner if s/s worsen or new s/s appear.
[/textarea]
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