SKIN: Skin is warm, dry, and pale. Normal. No rashes, hives, moles, verruca, infections, lesions, or bruising noted. Texture is smooth. Turgor is elastic. Hair is thick with no hair loss. QBC is within normal limits. No evidence of blistering. Slightly erythematous. Fairly dishidrotic eczema.
HEENT: Head: Head is symmetrical, atraumatic, and normocephalic. No masses, lumps, lesions, or infections noted. Eyes: Eyes are in alignment with adequate lacrimation. Sclerae and conjunctivae are clear. PERRL (PERRLA). EOM 3, 4, and 6 are intact. Wears glasses because nearsighted. Denies double or blurred vision, photosensitivity, eye pain, eye infection, or failing vision. Ears: External ears are free of inflammation. Canals are patent without exudate, excess cerumen, or foreign objects. Tympanic membranes are within normal limits. Tympanic membranes are pearly gray with cone of light. TM joints move freely (smoothly) without pain. TMs are injected bilaterally. Denies decreased hearing. Have some tinnitus particularly in his right ear. Denies ear infections or dizzy spells. Nose: Septum is non-deviated. Nares are patent. No discharge, polyps or foreign objects. Mucosa is pink and moist. Mucosa erythematous and moist. Denies nosebleeds, sinus problems, epistaxis, or seasonal allergies. Throat (Oropharynx): Posterior pharynx is clear. Tonsils are intact. Tonsillar fauces, pillars. Teeth are without dental caries. Tongue and mucosa are moist, soft and pink. No lesions or inflammations noted on hard or soft palate, buccal areas, or gingiva. Denies frequent sore throat. There is some drooling. Uvula is midline. Slightly erythematous. Throat is beefy red. No exudates.
RESPIRATORY: Thorax is symmetrical without scars, masses, lumps, or lesions. Lung sounds are clear without adventitious sound. Reports a slight cold as weather change and an occasional cough. Reports nighttime or nocturnal cough. Breathing is even and nonlabored without paradoxical movements or use of accessory muscles. Does complains of shortness of breath. Breasts have no masses. On breast exam in the left upper outer quadrant breast, there is a central blackened pore with surrounding discoloration of the skin. There is no acute infection present.
CARDIOVASCULAR: Auscultation at the pulmonary, aortic, tricuspid, and mitral areas reveal no murmurs, rubs, hums, clicks, or extra sound. Heart tones are strong, RRR, and in synchrony with the carotid pulse. PMI is unable to be palpated. Blood pressure on presentation. Denies chest pain, dysrhythmias, edema in extremities, syncope, leg cramps, or cyanosis. Does have some leg cramping.DIGESTIVE: Abdomen is soft, round, obese. No umbilical deviation. Unable to palpate the spleen or the hepatic border. Bowel tones present. No aortic bruit auscultated. Has been eating well and taking fluids well. Weight today is 119.5 as compared to 203.5 of last visit. No nausea or vomiting. No change in bowel habits. Reports no change in bowel movement. Denies difficulty swallowing other than the sore throat, indigestion, or heartburn. Vomited some clear phlegm in the past 24 hours. Denies black or bloody stools.
GENITOURINARY: No change in urinary habits. Denies discharge or itching, painful urination, hematuria, frequent or nocturnal urination. Occasionally wake up once through the night to urinate. Denies incontinence. No rashes around the scrotal area. Pruritus at the scrotum. No erythema or edema. Denies CVA tenderness or kidney pain.MUSCULOSKELETAL: Walks independently. Gait is smooth and even. Easy, even and steady gait. Ambulates easily. Has some mild spasticity. Range of motion appears to be within normal limits. Denies joint pain, cramping, swelling, or stiffness. Does report back pain. Left great toe is erythematous and edematous with some serous drainage on the lateral aspect. Does report pain to palpation.NEUROLOGICAL: The patient is alert, oriented, aware of circumstances, carries on appropriate conversation for age. CN 2 through 12 are intact. Has brisk reflexes and increased tone. Maintains balance well. Reports numbness and tingling in arms. There were neurological problems after the assessment was complete. Denies headache.
ENDOCRINE SYSTEM: Denies chronic fatigue, sudden weight change, excessive thirst or urination. Does report a dry mouth. Denies easy bruising, tremors, convulsions, muscle weakness, or heat or cold intolerance. Feels “rundown.” Has several stressors in life. Reports “anxiety attacks” times one month. Blood sugar today is 133. Sed rate is 12.
SAMPLES OF ROS
REVIEW OF SYSTEMS: HEENT: Rare nonfocal headache. Left ear feels clogged. PULMONARY: No shortness of breath, cough, hemoptysis. CARDIOVASCULAR: No chest pain, palpitation, PND, orthopnea, or ankle edema. GASTROINTESTINAL: Has been having more frequent reflux in the past several months. Bowels are good. GENITOURINARY: Not having any complaints. BACK/EXTREMITIES: No discomfort and no other complaints voiced.
REVIEW OF SYSTEMS: Denies any suicidal or homicidal ideation. Denies any fever, chills, or diarrhea. Denies any vomiting, iarrhea or constipation (or No constipation). No SOB. No chest pain. No palpitations or syncope. No cyanosis or apnea. No traumatic injury, visual disturbances, swallowing disorders. No hemoptysis, hematochezia, hematemesis, or melena. No burning, frequency, or urgency of urination. No abdominal pain, numbness or tingling of the extremities. No environmental allergies. No anxiety or depression, no homicidal suicide or ideation. No traumatic injuries other than MVA, no complaints of abdominal pain,
REVIEW OF SYSTEMS: Ten systems are reviewed and found to be negative unless mentioned per history of present illness.
REVIEW OF SYSTEMS: No fever or chills. No polyarthralgia in particular in the upper extremities. The patient only complains of pain in the knees and ankles which has been bothering for some time now. There has been no redness or open wound. No further review obtained.