ER visit with female pelvic exam

Chief Complaints: 
[textarea cols=80 rows=1 default=""]

HPI: 
[textarea cols=80 rows=5 default=""]

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

Soc Hx: 
[textarea cols=80 rows=2 default=""]

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=2 default="EYES: EOMI, conjunctivae not injected, sclera anicteric"]
[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: RRR, S1 and S2, no peripheral edema"]
[textarea cols=80 rows=2 default="ABD/GI: nontender to palpation, nondistended, +bowel sounds, soft abdomen"]
[textarea cols=80 rows=2 default="GU: external genitalia normal appearing, minimal blood in vaginal vault, os close, no CMT, no adnexal mass"]
[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:"]


Diagnoistic Studies: 
[textarea cols=80 rows=1 default="EKG:"]
[textarea cols=80 rows=1 default="XRAYS:"]
[textarea cols=80 rows=1 default="Labs:"]
[textarea cols=80 rows=1 default="CT:"]


MDM:
[textarea cols=80 rows=2 default="DDx:"]
[textarea cols=80 rows=2 default="ED Course:"]
[textarea fillable="true" cols=80 rows=1 default="Diagnosis:******"]
[textarea fillable="true" cols=80 rows=2 default="Plan:******
Return to ED precautions discussed. Follow up with PCP."]