REVIEW OF SYSTEMS:
GENERAL/CONSTITUTIONAL: The patient has been feeling more tired. Other than that, no other symptoms. No weight loss, no night sweats, no fever or chills.
CARDIOVASCULAR: No prior history of any cardiac problem and no chest pain until last month.
PULMONARY: No history of any lung problem, asthma, pneumonia or bronchitis.
GENITOURINARY: No dysuria or hematuria.
GASTROINTESTINAL: Has some acid reflux. No hematemesis or melena.
RHEUMATOLOGY: The patient has history of osteoarthritis.
ENDOCRINE: The patient has diabetes and has been on medication. She has been diagnosed with hypothyroidism and has been on Synthroid.
PSYCHIATRIC: Mild depression.
NEUROLOGICAL: Negative.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative for fever, weight loss or weight gain.
HEENT: Eyes: Negative for glaucoma or cataracts. Ears: Negative pain or loss of hearing. Nose: Positive for nasal congestion. Negative for rhinorrhea or postnasal drip. Mouth: Negative for false teeth. Throat: Negative for masses or hoarseness. Positive for snoring.
CARDIOVASCULAR: Negative for chest pain or palpitations.
RESPIRATORY: See HPI.
GASTROINTESTINAL: Negative for nausea, vomiting, diarrhea or heartburn.
GENITOURINARY: Negative for dysuria.
MUSCULOSKELETAL: Positive for osteoarthritis.
SKIN: Positive for hives secondary to penicillin. Negative for rashes.
NEUROLOGIC: Positive for occasional sinus headaches.
PSYCHIATRIC: Positive for depression. Negative for daytime sleepiness or insomnia.
ENDOCRINE: Negative for diabetes or thyroid abnormalities.
HEMATOLOGIC: Negative for anemia or blood dyscrasias.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative for any fever, weight loss or weight gain.
HEENT: The patient has no visual problems. No sore throat. No sinus problems.
CARDIOVASCULAR: The patient has been on Coumadin for atrial fibrillation. Has had no chest pain, no paroxysmal nocturnal dyspnea.
PULMONARY: Denies any wheeze. Usually can ambulate a mile without shortness of breath. Infrequent bronchitis. Has no history of TB. Has never been told that he had asthma.
GASTROINTESTINAL: Denies any nausea, vomiting, hematochezia, hematuria or constipation. Has not had any difficulty with his liver.
GENITOURINARY: Denies any difficulty urinating.
NEUROLOGIC: Denies any history of CVA, mental status changes or visual changes. Has not had any seizures or paresthesias. No neurologic changes.
ENDOCRINE: Denies any diabetes or thyroid disease.
SKIN: Denies any skin lesions, except he has had a discolored red area on his left shin for many years. Has had some petechial rash over bilateral shins but no pruritus and no other rashes.
PSYCHIATRIC: Denies any psychiatric illness.
Rest of the review of systems was negative.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, no chills, no diaphoresis. Generalized weakness.
HEENT: Blurred vision, chronic frontal headache with runny nose. No sore throat, no ear pain.
CARDIOPULMONARY: Chest pain, shortness of breath on exertion, cough. Please see HPI. No orthopnea, no paroxysmal nocturnal dyspnea, no wheezing.
GASTROINTESTINAL: Pleuritic pain. No nausea, no vomiting, no dysphagia, possible heartburn with chronic epigastric pain, no reflux, no regurgitation, no hematemesis, no abdominal pain, no constipation, no hematochezia, no melena. Diarrhea last night.
GENITOURINARY: No dysuria, no hematuria, no flank pain, nocturia x4, no incontinence.
MUSCULOSKELETAL: Lower back pain for 5 years.
NEUROLOGIC: Numbness intermittently in both lower legs, not at the time of admission.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient has not had recent weight change or fever.
CARDIOVASCULAR: Had no chest discomfort, orthopnea, PND or edema.
RESPIRATORY: Occasional cough. No wheezing or hemoptysis.
GASTROINTESTINAL: No abdominal pain, nausea, vomiting, diarrhea, hematochezia or jaundice.
GENITOURINARY: No frequent nocturia. No dysuria.
MUSCULOSKELETAL: Occasional arthralgias. No major arthritis.
SKIN: No rash, itching or suspicious lesions.
NEUROLOGIC: Memory impairment is noted. No motor deficit, numbness or frequent headaches.
ENDOCRINE: Denies polydipsia, polyuria, heat or cold intolerance.
HEMATOLOGIC: No abnormal bleeding or bruising or lymphadenopathy.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Has a subjective fever, but no chills, no weight loss, no change in her appetite. No night sweats.
SKIN: There is a wound to her left foot. There were no other skin rashes.
HEENT: Negative for URI symptoms, conjunctivitis, eye pain, sinus tenderness, runny nose, sore throat or lymph node enlargement. No mass in her neck. Hearing and vision have been normal.
CARDIOVASCULAR: Denied any chest pain, palpitation, orthopnea or dyspnea. Did have left leg edema and swelling, but normal to the right side.
RESPIRATORY: Denied any cough, hemoptysis, wheezing, history of asthma or any shortness of breath. Denies any history of tuberculosis.
GASTROINTESTINAL: Denied nausea, vomiting, abdominal pain, bloody stool, melena or hematochezia.
GENITOURINARY: Denied any dysuria, urgency, any leukorrhea or any abnormal vaginal discharge.
MUSCULOSKELETAL: Denied any joint pain or joint swelling except to the left foot, which has overall pain and is tender since the injury.
NEUROLOGIC: Denied any focal muscle weakness, neurological or sensation abnormalities. No loss of consciousness. No chronic headache. No other neurological deficit. No history of seizure.
