General note

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ROS:    General: The patient reports no significant weight changes, fevers, or fatigue. 
Skin: Denies any rashes, itching, or lesions. No changes in moles or new growths noted. 
Head: No headaches, head injuries, or dizziness reported. 
Eyes: No changes in vision, blurred vision, or double vision. No eye pain, redness, or discharge noted. 
Ears, Nose, Throat: Denies any hearing loss, ear pain, tinnitus, or drainage from the ears. No nasal congestion, epistaxis, or sinus pain. No sore throat, hoarseness, or difficulty swallowing. 
Respiratory: No cough, shortness of breath, wheezing, or chest pain. Denies hemoptysis or sputum production. 
Cardiovascular: No chest pain, palpitations, or edema reported. No history of heart murmurs or irregular heartbeats. 
Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or abdominal pain. No changes in appetite or difficulty swallowing. No heartburn or indigestion reported. 
Genitourinary: No dysuria, frequency, urgency, or hematuria. No flank pain or changes in urinary habits. 
Musculoskeletal: No joint pain, swelling, stiffness, or limited range of motion. No muscle weakness or deformities noted. 
Neurological: No numbness, tingling, weakness, or changes in sensation. Denies seizures or tremors. 
Psychiatric: Denies depression, anxiety, hallucinations, or mood swings. No history of suicidal ideation or attempts. 
Endocrine: No heat or cold intolerance reported. No changes in weight, appetite, or energy levels. 
Hematologic/Lymphatic: No history of easy bruising, bleeding gums, or prolonged bleeding. No swollen lymph nodes or frequent infections. 

ASSESSMENT    AND    PLAN    
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