PE and ROS without complications
PHYSICAL EXAM: GENERAL: Alert and oriented x 3. No acute distress. Well-nourished. EYES: EOMI. Anicteric. HENT: Moist mucous membranes. No scleral icterus. No cervical lymphadenopathy. LUNGS: Clear to auscultation bilaterally. No accessory muscle use. CARDIOVASCULAR: Regular rate and rhythm. No murmur. No JVD. ABDOMEN: Soft, non-tender and non-distended. No palpable masses. EXTREMITIES: No edema. Non-tender. SKIN: No rashes or lesions. Warm. NEUROLOGIC: No focal neurological deficits. PSYCHIATRIC: Cooperative. Appropriate mood and affect. ----------------------------------------------------------------- ROS: CONSTITUTIONAL: Denies weight loss, fever and chills. HEENT: Denies changes in vision and hearing. RESPIRATORY: Denies SOB and cough. CV: Denies palpitations and CP. GI: Denies abdominal pain, nausea, vomiting and diarrhea. GU: Denies dysuria and urinary frequency. MSK: Denies myalgia and joint pain. SKIN: Denies rash and pruritus. NEUROLOGICAL: Denies headache and syncope. PSYCHIATRIC: Denies recent changes in mood. Denies anxiety and depression.
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