Monday, July 12, 2010

Review of Systems (ROS)

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.

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.


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.

Saturday, November 25, 2006


Head, Eyes, Ears, Nose and Throat

atraumatic, normocephalic (AT/NC)
Battle's sign (cap the "B" - named for Dr. William H. Battle)
facial pain
flattening of the (left/right) nasolabial fold
fontanel (infant exam)
normocephalic, atraumatic (NC/AT)

abnormal A-V ratio
altered eye motion
arcus senilis
arterial pulsation
A-V crossing change
Battle's sign
best-corrected visual acuity
black eye
blood or hemorrhage in eye
blurred vision
change in size, shape of pupils
change in the color of the iris
conjunctivae pink, not injected, clear, normal, muddy, no pallor
cornea clear/cloudy
corneal reflex intact
crusty, swollen, inflamed eyelids
darkness around or under the eyes
decreased night vision
disk/disc margins well-delineated
disks/discs sharp
double vision
dry eyes
excessive tearing, watering
extraocular movements (EOM) (may be dictated EE-OHM)
extraocular movements intact (EOMI) (may be dictated EE-OH-MEE)
focal constrictions
foreign object in the eye
fundi well-visualized/not well-visualized/not examined
funduscopic examination, funduscopy
H or E (hemorrhage or exudate)
hard exudates
homonymous hemianopsia
increased cup to disc ratio
irregular pupil
isocoria/isocoric (meaning the pupils are equal bilaterally)
itchy or burning eyes
lenticular opacification
limbal injection
lumps, bumps, sores on the lids
macular degeneration
medullated nerve fibers
nonreactive/hyporeactive pupil
ocular swelling
optic atrophy
pain in or around the eye
pigmentary disturbance
preretinal and retinal hemorrhage
protruding eyes
ptosis (pronounced TOH-SIS)
ptosis of eyelids
Pupils (fixed/dilated/pinpoint)
Pupils equal and reactive to light. (PERL)
Pupils equal, round, and reactive to light and accommodation. (PERRLA)
Pupils equal, round, and reactive to light. (PERRL) (above may be dictated as PURL or PURL-LAH)
raccoon eyes
rapid eye movements (REM)
red eye
red or pink eyes
red reflex
reduced vision
sclerae anicteric/icteric
slit-lamp examination
soft exudates
strabismus/lazy eye
swelling around the eyes
visual acuity

Eye Pathology
Age Related Eye Conditions: Cataract, Glaucoma, Macular Degeneration, Presbyopia
Congenital Defects: Congenital cataracts
Degenerative Diseases: Retinitis pigmentosa
Eyelid Disorders: Blepharitis, Chalazion, Ectropion, Entropion, Pinguecula, Pterygium, Ptosis, Sty/Hordeolum, Hypoxia/Hyperoxia, Retinal vessel occlusion
Infection: Blepharitis, Conjunctivitis, Corneal ulcers and infections
Eye Inflammation: Chemosis, Episcleritis, Hypertensive retinopathy, Optic neuritis, Scleritis, Uveitis
Others: Amaurosis fugax, Amblyopia, Astigmatism, Blindness, Blocked tear duct, Coloboma of the iris, Colorblindness, Corneal injury, Dacryoadenitis, Eye floaters, Farsightedness, Gonococcal Ophthalmia, Keratoconjunctivitis sicca, Keratoconus, Melanoma of the eye, Nearsightedness, Optic atrophy, Optic Glioma, Retinitis Pigmentosa, Retinoblastoma, Retrolental Fibroplasia, Strabismus, Tay-Sachs disease

auditory canal
myringotomy tubes
poor light reflex
TMs (tympanic membranes)
tympanic membranes intact - red/bulging/dull
hearing loss
equilibrium/balance problems
ear ache/pain
fullness, tickling, itching in ear
tinnitus/ringing in the ear
lumps, bumps or sores in ear
swimmers ear

Ear Pathology
Acoustic Trauma, Acute otitis media, Age-related hearing loss, Aural polyps, Barotitis, Benign ear cyst or tumor, Cholesteatoma, Chronic otitis media, Chronic Suppurative Otitis, Ear barotraumas, Ear discharges,bleeding, Ear foreign body, External otitis, Genetic Sensorineural Hearing Loss, Granulomatous Diseases, Infectious myringitis, Labyrinthitis, Labyrinthitis Ossificans, Mastoiditis, Meniere's disease, Middle Ear, Benign Tumors, Noise-Induced Hearing Loss, Occupational hearing loss, Otitis externa; acute, Otitis externa; chronic, Otitis media, Otitis Media with Effusion, Otosclerosis, Otosclerosis, Ototoxicity, Patulous Eustachian Tube, Perilymphatic Fistula, Pina abnormalities and low set ears, Presbycusis, Ramsay Hunt syndrome, Ruptured ear drum, Sensorineural deafness, Serous otitis, Sudden Hearing Loss, Syndromic Sensorineural Hearing Loss, Tympanic Membrane Perforations, Vascular obstruction, Wax blockage

Diagnostic and Treatment Procedures
Cochlear Implants, Fractionated Stereotactic, Implantable Hearing Devices, Middle Ear Endoscopy, Myringotomy, Ossiculoplasty, Radiation for Acoustic Neuroma

External ear, aural atresia
Related keywords: auricular atresia, congenital auricular deformity, small auricle, microtia, anotia, lop ear, cup ear, Stahl ear, peanut ear, anotic ear, peanut deformity, hypoplasia, hypoplastic ear, prominent ear, hemifacial microsomia, Goldenhar syndrome, Treacher Collins syndrome, Franceschetti syndrome, oculoauricular vertebral dysplasia, ear deformity, aural atresia, ear reconstruction

Preauricular Cysts, Pits, and Fissures
Related keywords: preauricular tags, epithelial mounds, pedunculated skin, preauricular sinus pit, sinus tracts, subcutaneous cysts, branchiootorenal syndrome, BOR syndrome, Beckwith-Wiedemann syndrome, mandibulofacial dysostosis, oculoauriculovertebral dysplasia, chromosome arm 11q duplication syndrome, chromosome arm 4p deletion syndrome, chromosome arm 5p deletion syndrome, preauricular cysts, pits, and fissures

bloody nose/epistaxis
boggy turbinates
dry nose
excessive sneezing
flattening of the nasolabial fold
inferior turbinate
itchy nose
loss of smell/anosmia
nasal congestion/obstuction
nasolabial fold
postnasal drip
runny nose/excess nasal discharge
septal deviation
turbinate/turbinate hypertrophy

Nose Pathology
Epistaxis / Nosebleeds, Foreign body nose, Nasal polyps, Nasal Polyps, Nose Fracture, Nosebleed – injury, obstructive sleep apnea, Rhinophyma, Seasonal Rhinitis, Sinusitis, Vasomotor rhinitis

aphthous ulcers
bifid uvula
buccal mucosa
cleft palate
difficulty swallowing/dysphagia
hard palate
hoarseness/loss of voice
mucous membranes moist/dry
protruded tongue midline
soft palate
sore throat
temporomandibular joint
tongue well-papillated
uvula and tongue midline
uvula moves on phonation

Breath odor, Canker sores, Chapped lips, Cleft lip and palate, Fever blister, Follicular tonsilitis, Geographic tongue, Gingivitis, Glossitis, Glossopharyngeal neuralgia, Herpes labialis, Leukoplakia, Macroglossia, Mouth ulcers, Oral cancer, Oral candidiasis (adult), Periodontitis, Perioral dermatitis, Pharyngitis, Posterior tongue carcinoma, Tongue tie, Tonsilitis

Tonsillitis and Peritonsillar Abscess
Related keywords: tonsillitis and peritonsillar abscess, quinsy, acute tonsillitis, recurrent tonsillitis, chronic tonsillitis, pharyngitis, pharyngotonsillitis, adenotonsillitis, PTA, inflammation of the pharyngeal tonsils, lingual tonsillitis, group A beta-hemolytic Streptococcus pyogenes, GABHS, GABHS pharyngitis, adenoidectomy, trismus, quinsy tonsillectomy, abscessed tonsil, bilateral tonsillectomy, sore throat, throat infection

Related keywords: adenoidectomy, adenoid surgery, adenoid removal, infected adenoids, pediatric adenoidectomy, pediatric adenoid removal, pediatric adenoid surgery, tonsillectomy and adenoidectomy, T&A, adenoiditis, tonsillectomy, middle ear effusion, otitis media, OM, middle ear infection, rhinosinusitis, ear infection, ear disease, chronic sinusitis, COM, AOM, acute otitis media, chronic otitis media, otitis media with effusion, OME, adenoid curette, adenoid punch

Velopharyngeal Insufficiency
Related keywords: velopharyngeal insufficiency, VPI, velopharyngeal incompetency, velopharyngeal dysfunction, VPD, hypernasality, resonance disorders, cleft palate, palatoplasty, pharyngeal flap, pharyngoplasty, velocardiofacial syndrome, VCF syndrome, Kabuki syndrome, KS, Shprintzen syndrome

carotids 2+ and equal bilaterally,
carotid bruit, cervical adenopathy, goiter, hepatojugular reflux (HJR), jugular venous distention (JVD), lymph nodes not palpable/palpable, hard, immobile, fixed, freely mobile, lymphadenopathy, multinodular goiter, pharynx, shotty lymph nodes [NOT shoddy], stridor, supple, thyroid not palpable, thyromegaly, venous distention at 45 degrees

Thyroid enlargement

3-D X ray
CT scan
Ear tubes are small plastic or metal tubes
Eustachian Tube Placement
Examination of mouth and throat
Examination of nose and sinuses
Fluorescein techniques
Headache evaluation
Nasoscopic examination
Neck examination (thyroid gland and lymph nodes)
Ophthalmoscopic examination
Otoscopic examination
Pulsatile irrigation
Rapid strep test
Sinus CT Scan
Slit lamp evaluation
Standard tests of vision and hearing
Temperomandibular (TMJ) pain
Xoran Mini CT Scanner for sinus, ear, and TMJ visualization
X-ray imaging

Treatment techniques
Cervical lymphatic enhancement
Ear "adjustment" (J)
Ear acupoint stimulation
Ear pump
Eustachian tube opening decongestion technique
Irrigation of the ear/ cerumen removal
Lid flipping and foreign body removal techniques of the eye
Sinus acupoint stimulation
Sinus percussion/stimulation techniques
Sinus pump
Suboccipital stretch

Physical Examination (PE)


VITAL SIGNS: Temperature, pulse, blood pressure, respiratory rate, weight, and height. Oxygen saturation on room air is 96%. Afebrile.
GENERAL: Alert, cooperative (age/gender) in NAD. Reveals a well-developed, well-nourished, well-hydrated male in no acute distress. Sitting comfortably on the examining table. Normal affect. Cachetic. Appearing alert and comfortable; looks normal self. The patient is awake, alert x3 in no acute distress.
SKIN: Normal. No rash, ecchymosis, erythema or drainage. No hematoma. No cyanosis. No lesions.
HEENT exam: Unremarkable. Reveals the head to be normocephalic and atraumatic. Eyes: PERRLA; EOMS are intact bilaterally; red reflex is also present bilaterally. Fundoscopic examination is unremarkable for hemorrhages, exudates or papilledema. Sclera is white. Conjunctiva is pink. Extraocular muscles: Intact. Sclera is anicteric. Ears: Clear. TMs are pearly gray with good cone of light. TMs erythematous, bulging bilaterally and poorly movable to pneumatic otoscopy. TMs were clear. TMs are dull, retracted.
Nose: Nasal passages pink and moist, clear (free) rhinorrhea. Throat: Beefy red, no exudates. Clear and free of erythema. Strep test is positive. Buccal mucosa is pink and moist as is the tongue. Posterior pharynx was normal. Facial musculature is atrophic with considerable amount of atrophic changes around the lips, cheeks, and gums.
NECK: Supple with shoddy cervical lymphadenopathy. Trachea is midline. Carotid arteries negative for bruits bilaterally. No tenderness to palpation over the bony prominences of the cervical spine. No nuchal rigidity or meningeal signs. There is no JVD. No thyromegaly or JVD, carotids 2+, no bruits. Neck is obese. Neck veins are difficult to assess. Neck veins are nondistended. Carotid impulses were normal although the right side exhibited a louder systolic murmur to the left. There is no thyromegaly. Neck veins are flat. The carotids are quiet. Neck is supple, JVD is not appreciated. Thyroid is not palpable. Denies neck swelling.
HEART: NSR without murmur. RRR. Regular rate and rhythm. S1 and S2 without murmurs. Normal S1 and S2, without murmur, gallop, click, or rub. PMI is poorly palpable. Heart tone is somewhat distant. There is an S1 and S2, no S3, soft murmur. Audible heart tones with a grade 1/6 systolic murmur. Regular cardiac rhythm with a fourth heart sound and a grade 1/6 systolic ejection murmur at the base without radiation.
Cardiac examination revealed an impalpable apical impulse, a normal S1 and S2 with normal intensity, splitting not heard, and a grade 2/6 mixed frequency midsystolic murmur of the base in the left sternal border. No diastolic murmur or gallop. Cardiac exam reveals a regular rhythm with no murmurs or gallops. Cardiac exam: S1 and S2, irregular rhythm.
LUNGS: Clear to auscultation and percussion with some upper respiratory rhonchi with expiratory wheeze, rales at the bases. No tenderness to AP and lateral compression of the chest wall. Diaphragmatic excursion is nominal. Has tenderness to palpation over the left chest especially anteriorly. No adventitious sounds. Lungs are clear with a reasonably good air exchange.
ABDOMEN: Soft, nontender. No appreciable masses (or no masses noted). No organomegaly. Bowel sounds present in all four quadrants. They are normoactive. No hepatosplenomegaly, masses, or tenderness. Benign without organomegaly. The abdomen was obese and detected no organomegaly.
External genitalia was normal. Vaginal cuff was normal. No pelvic masses or tenderness.
RECTAL EXAM: Rectum had some external or slightly inflamed hemorrhoids. Internally, no masses, brown heme negative stools.
EXTREMITIES: No edema, good peripheral pulses. Within normal developmental limits, symmetrical without edema. Show rheumatoid type remodeling, considerable atrophy of the muscles, swelling of the hand. There is trace 1+ edema. Extremities exhibited no clubbing and cyanosis and pedal pulses were not detected. Good capillary refill.
BACK: No palpable tenderness on the thoracolumbar paraspinous musculature on the left. No spasm. No midline tenderness, crepitus, or stepoff. Able to stand on his toes. Able to stand on his heels and do deep knee bend. Good patellar and Achilles reflexes. Good sensation in the lower extremities. No tenderness over the spine itself; hip flexion-extension is preserved. Interestingly enough, right medial quadriceps is atrophied as compared to the left side but its strength is preserved. No pain with either straight leg raises, ankle flexion-extension, eversion and inversion are all preserved. Sensation to light touch, pin prick, and vibration is intact. Pulses are normal.
NEUROLOGICAL (or CNS): CN 2 through 12 are grossly intact as are motor and sensory sub-systems.
The remainder of examination is essentially nominal. CNS is nonfocal. Neurological examination does not reveal any focal or lateralizing deficits. Funduscopic examination is unremarkable. No evidence of afferent pupillary defect or nystagmus; otherwise, II-XII intact.
MOTOR EXAM: 5/5. Normal bulk and tone. 5/5 in left upper extremity and bilateral lower extremity, 4/5 right toe dorsiflexion. Right upper extremity reveals cortical hand with flexed fingers in a grip position, biceps and triceps is 4/5, deltoid is 5/5. She cannot extend her fingers.
REFLEXES: 2+. Toes are downgoing. 3+ in right upper extremity and lower extremity, 2+ left upper extremity. Right toes are upgoing. Left toes are downgoing.
COORDINATION: Intact, other than right upper extremity which revealed dysdiadochokinesis.
GAIT: Steady. Reveals right foot drop which is mild; otherwise, steady.
Exam is stable and is documented in the office record.
MENTAL STATUS EXAM: Alert and oriented x3. No tics or dyskinesias. Mood: Reported as “not very good.” Affect was tearful. No suicidal or homicidal ideation.

PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is alert and oriented x3. VITAL SIGNS: Temperature is 97.8, pulse is 75, respirations are 18, and blood pressure is 160/85 on presentation. Oxygen saturation is 96% on room air. SKIN: Warm, dry, no rash. HEENT: Normocephalic and atraumatic. No perioral or periorbital edema. Eyes: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Conjunctivae sacs are injected. The ears, nose, and throat are clear. NECK: Supple. No adenopathy or meningeal signs. No meningismus. CHEST: LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, without murmurs. ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds. No visceromegaly. SKIN: Moist. Good turgor without any rash, petechiae, bullae, or purpura. NEUROLOGIC: Cranial nerves II through XII are grossly intact without focal or neurologic deficits. EXTREMITIES: No clubbing, cyanosis, or edema. Distal neurovascular functions in the legs are maintained. Legs are very thin. There is no calf or popliteal involvement. Achilles unremarkable. Foot exam normal bilaterally. No specific tenderness on the right ankle was identified or has “soreness” on both ankles. Smooth range of motion noted. Ankle and knee joints are cool. No overlying erythema, evidence of trauma, evidence of DVT, or infection. Knee joints are within good range of motion as well although, they “ache.” No gross laxity or effusion noted.

PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is a delightful, pleasant 26-year-old who is alert and oriented to person, place, time, and purpose, and appropriate for situation. VITAL SIGNS: Blood pressure 120/80 initially with a recheck of 115/70, pulse 85 and regular, weight 145 lbs which is stable. HEENT: Conjunctiva clear, no exophthalmos. Mucous membranes are pink and moist. NECK: No thyromegaly, jugular venous distention or carotid bruits. LUNGS: Equal and symmetrical expansion, clear throughout to auscultation. Cardiac: Audible S1 and S2. No murmurs, rubs or gallops appreciated. ABDOMEN: Nontender. EXTREMITIES: Radial pulses 2+ bilateral. Posterior tibial pulses 2+ bilateral. No peripheral edema. No clubbing. SKIN: No cyanosis.

PHYSICAL EXAMINATION: Temperature is 98, pulse 60, respirations 20, blood pressure is 130/80, Oxygen saturation is 96%. Peak flow is at 145 prior to nebulizer treatment in the office today. Speech is sluggish but normal. Skin is warm and dry. Color is pinkish tan. Turgor is good. HEENT: TMs are dull. Nares are patent with pink turbinates. Posterior oropharynx: Slightly injected. Oral mucosa: The patient has erythema to the roof of the mouth, several missing teeth, several with really bad gingivitis. Neck is supple with enlarged lymphs in the anterior cervical chain, none in posterior. No thyromegaly . Chest: Heart rate is regular. Lungs are clear to auscultation. Respiratory rate is regular. Chest expansion is equal bilaterally. No sternal or axillary node is palpable. Report pain at a level 7-1/2 in his leg and the head.

PHYSICAL EXAMINATION: Afebrile. Weight 130 pounds, temperature 99.7, heart rate of 100, blood pressure 120/70, oxygen saturation 94% on room air. In general, this is a thin, teary-eyed patient, alert, pleasant, in no apparent distress. Neck veins are flat. Lungs are clear. Heart S1, S2. On S1 and S2, evidence of pectus excavatum noted with anterior chest wall deformity. Lungs: Rhonchi present bilaterally, no crackles, no wheezes. Exam of nostrils: No obvious evidence of polyps, but with evidence of deviated nasal septum noted. Cardiovascular exam is normal. Pelvic exam: Visual exam of the vulva and perineal area was done only. The patient has multiple vesicles noted at the perineum with several scattered papules over the labia majora. Abdomen is soft, nontender. Extremities: No edema. (Trace ankle edema.)

LABORATORY: Basic metabolic panel, free T4, and TSH which are currently pending. Urinalysis does reveal 1+ leukocytes, positive nitrites, 1+ protein, trace of blood, 1+ ketone, 1+ bilirubin, remainder negative. Urine pregnancy test is negative. LCR is currently pending. CBC: Normal except for white count of 4300. Pancreas metabolic profile: Normal. Total cholesterol 167 with HDL 69, LDL 75. WBC count today is 8.8 with a 73/27 differential. QBC is in the chart. Remainder of the examination is essentially nominal. Chemistries: Creatinine has gone up. The rest seems to be stable.

RADIOGRAPHIC EXAMINATION: Shows increased broncho-pulmonary markings, bronchial wall cuffing, infiltrates bilaterally. Review of previous x-ray does show what appears to be two fractures on the anterior ribs. Previous film was read for congestion.

Electrocardiogram: EKG demonstrates sinus rhythm. Inferior and lateral ST depression and without significant change compared with previous EKG.
A 12-lead electrocardiogram today demonstrates a sinus rhythm at 70 bpm with left anterior fascicular block and nonspecific intralateral ST-T wave changes.