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. CN II-XII grossly intact, but not individually tested.
- PSYCHIATRIC: Cooperative. Appropriate mood and affect.
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ROS:
- CONSTITUTIONAL: Denies weight loss, fever and chills.
- HEENT: Denies changes in vision and hearing.
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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.
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NEUROLOGICAL: Denies headache and syncope.
- PSYCHIATRIC: Denies recent changes in mood. Denies anxiety and depression.
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