REVIEW OF SYSTEMS:
GENERAL: The patient complains of fatigue. No headaches or dizzy spells.
HEENT: The patient does have glaucoma. She has decreased vision and is blind in the right. Sinuses: No complaints.
CARDIOPULMONARY: She gets swelling of the legs but no chest pain. She does have shortness of breath, no wheezing.
GASTROINTESTINAL: She has frequent heartburns. Has known gastroparesis. Denies both diarrhea and constipation, blood or mucus.
GENITOURINARY: She denies dysuria, bleeding and incontinence.
MUSCULOSKELETAL: She has a lot of arthritic complaints including stiffness, weakness.
She has slow healing. The patient seems to be feeling well.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
REVIEW OF SYSTEMS: The patient denies any fever, weight change. Denies any sore throat, ear pain, rhinorrhea. Denies any double vision, blurred vision or eye pain. Denies any shortness of breath, cough or pleuritic chest pain. The patient denies any nausea, vomiting or diarrhea. The patient does not have any dysuria, frequency or urgency. The patient does have myalgias in the back and legs from the sickle cell pain but no bony tenderness. The patient does have a history of anemia and has required transfusions in the past. He denies any bleeding or easy bruising.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI.
HEENT: Eyes: No diplopia or blurred vision. ENT: No earache, sore throat or runny nose.
CARDIOVASCULAR: No pressure, squeezing, strangling, tightness, heaviness or aching about the chest, neck, axilla or epigastrium.
RESPIRATORY: No cough, shortness of breath, PND or orthopnea.
GASTROINTESTINAL: No nausea, vomiting or diarrhea.
GENITOURINARY: No dysuria, frequency or urgency.
MUSCULOSKELETAL: As per HPI.
SKIN: No change in skin, hair or nails.
NEUROLOGIC: No paresthesias, fasciculations, seizures or weakness.
PSYCHIATRIC: No disorder of thought or mood.
ENDOCRINE: No heat or cold intolerance, polyuria or polydipsia.
HEMATOLOGICAL: No easy bruising or bleeding.
REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies fevers, denies recent illnesses. EYES: Denies any vision changes. ENT: Denies any throat pain. NECK: Denies any neck pain. CARDIOVASCULAR: Denies chest pain. Denies palpitations. RESPIRATORY: Denies shortness of breath, denies cough, denies history of asthma or any pulmonary illnesses. GASTROINTESTINAL: Positive for nausea as described above which has now resolved. Negative for emesis. Positive for abdominal pain. Negative for diarrhea. GENITOURINARY: Negative for dysuria. Negative for urinary frequency or urgency. MUSCULOSKELETAL: Negative for extremity pains or joint discomfort. NEUROLOGIC: No change in sensation or paresthesias. SKIN: No rashes. Abdominal incisions are healed without any dehiscence, fluid leaking or pain.
REVIEW OF SYSTEMS: The patient denies weight loss, fever, rash, dizziness, headache, mood change, muscle weakness, numbness, change in vision, ear pain, sinus problems, sore throat, chest pain, leg swelling, shortness of breath, cough, nausea, vomiting, bloody stools, diarrhea, constipation, abdominal pain, kidney disease, painful urination, joint pain or anemia.
REVIEW OF SYSTEMS: Vision: Wears glasses for reading. Has routine eye exams. No hearing loss. Pulmonary: Denies coughing, wheezing or shortness of breath. Cardiovascular: No chest pain with exertion, PND or edema. Gastrointestinal: Denies acid reflux, heartburn, nausea, vomiting or rectal bleeding. Had a colonoscopy in the year XXXX. Gynecologic: She is status post menopause.
REVIEW OF SYSTEMS: Head: No headaches. No dizziness. Ears: No changes in hearing. Nose: No rhinitis. Throat: No dysphagia. Lungs: No dyspnea, wheezing or coughing. Cardiac: No palpitations or chest pain. Abdomen: No GI upsets, constipation or diarrhea. Genitourinary: No dysuria. No UTIs. Breasts: No breast lumps. Gynecologic: Her last Pap was about 1 year ago; it was normal. Her last few Paps have been normal. Neurologic: No numbness or tingling in her legs. Psychiatric: Positive for anxiety.
REVIEW OF SYSTEMS: No bone pain, falls, fractures, headaches, focal neurologic deficits, nausea, vomiting, hematemesis, hematochezia, melena, hematuria, dysphagia, odynophagia, pleurodynia, hemoptysis, weight loss, unexplained fever or pyogenic infection.
REVIEW OF SYSTEMS: The patient feels a little malaise and fatigued with lower abdominal tenderness over the uterus and surgical incision. The surgical incision is otherwise clean. There is no redness or purulent discharge. She is breastfeeding her baby. There is no breast tenderness or nipple cracking or discharge. There is a mild headache, slightly irritated throat, but there are no cervical painful lymph nodes. No neck stiffness. No difficultly breathing, coughing or sputum production. No back pain or dysuric symptoms. No calf swelling or joint tenderness.
REVIEW OF SYSTEMS: The patient is not currently having problems with headaches, dizziness, trouble swallowing, visual disturbances, hearing loss, cough or chest pain. She does note some shortness of breath in the mornings and evenings, but it is not associated with exercise. She has not had abdominal pain, nausea, vomiting, diarrhea, blood in the stool, difficulty with urination, weakness or numbness in the legs, but she has had some skin problems on her arms, which she has difficulty explaining.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No night sweats. No fatigue, malaise, lethargy. No fever or chills.
HEENT: Eyes: No visual changes. No eye pain. No eye discharge. ENT: No runny nose. No epistaxis. No sinus pain. No sore throat. No odynophagia. No ear pain. No congestion.
BREASTS: No breast pain, soreness, lumps, or discharge.
RESPIRATORY: No cough. No wheeze. No hemoptysis. No shortness of breath.
CARDIOVASCULAR: No chest pains. No palpitations.
GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. No diarrhea or constipation. No hematemesis. No hematochezia. No melena.
GENITOURINARY: No urgency. No frequency. No dysuria. No hematuria. No obstructive symptoms. No discharge. No pain. No significant abnormal bleeding.
MUSCULOSKELETAL: No musculoskeletal pain. No joint swelling. No arthritis.
NEUROLOGICAL: He had an episode of mild confusion. He has chronic right hemiplegia. No headache or neck pain. No syncope or seizure.
PSYCHIATRIC: He gets occasionally confused.
SKIN: No rashes. No lesions. No wounds.
ENDOCRINE: No unexplained weight loss. No polydipsia. No polyuria. No polyphagia.
HEMATOLOGIC: No anemia. No purpura. No petechiae. No prolonged or excessive bleeding.
ALLERGIC AND IMMUNOLOGIC: No pruritus. No swelling.
REVIEW OF SYSTEMS: The patient denies any headaches, lightheadedness or dizziness. No fever, chills or night sweats. No hemoptysis, hematemesis, hematuria or bright red blood per rectum. She denies any chest pain or chest tightness. No palpitations, paroxysmal nocturnal dyspnea or orthopnea. She does describe shortness of breath and dyspnea on exertion. She has a dry nonproductive cough. No history of pulmonary embolism or deep venous thrombosis. No heat or cold intolerance. She denies any history of thyroid disease. She states she has a stable appetite. No significant weight gain or weight loss. She denies any urinary symptoms. Remainder of her review of systems is as noted in the history of present illness.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies any fever or chills generally, and he denies any recent weight loss or weight gain. HEENT: The patient denies any headaches, any vertigo, any sore throat or rhinorrhea. Eyes: The patient denies any double or blurred vision or eye pain. CARDIOVASCULAR: The patient denies any chest discomfort, chest pain, irregular rhythm, tachycardia or diaphoresis. RESPIRATORY: The patient denies any cough or shortness of breath or wheezing. GASTROINTESTINAL: The patient denies any nausea, vomiting, diarrhea or abdominal pain. GENITOURINARY: The patient denies any dysuria, frequency, urgency or hematuria. MUSCULOSKELETAL: The patient denies any myalgias, arthralgias or edema. SKIN: The patient does have erythema on the skin. He has pain on the skin, particularly the antecubital fossa and forearm. He does have swelling of the forearm. NEUROLOGIC: The patient denies any weakness, dizziness, focal neurological change or headache. PSYCHIATRIC: The patient does have a history of depression in the past, but denies any suicidal ideation. He specifically denies any substance abuse. ENDOCRINE: The patient denies any polyuria, polydipsia or hot or cold intolerance. HEMATOLOGIC: The patient denies any history of easy bruising, anemia or eczema.
REVIEW OF SYSTEMS:
GENERAL: The patient’s weight is up and down. Her appetite has been poor. She has had difficulty going to sleep and staying asleep, and she has been very fatigued and tired. She does feel hot at times, never had a fever, just feels hot. Vision is negative.
HEENT: She feels like she has command voices in her head and she gets sick easily. She has had a sore throat and cold in the last 2 weeks.
CARDIOVASCULAR: She gets chest pain and palpitations with anxiety and shortness of breath with exertion.
RESPIRATORY: She has shortness of breath and wheezing.
GENITOURINARY: Negative. Her last Pap was done by myself approximately 3 or 4 months ago.
MUSCULOSKELETAL: She has had knee pain and she needs to have it repaired, ACL or MCL, one of the tendons is torn.
NEUROLOGIC: History of seizures. She gets headaches a couple times a week.
HEMATOLOGIC AND LYMPHATIC: She bruises easily.
ALLERGIC AND IMMUNOLOGIC: Negative.
REVIEW OF SYSTEMS: As stated above in the HPI, significant for rhinorrhea, congestion, cough, sore throat, nausea, vomiting, generalized fatigue. She has otherwise been well without abdominal pain, chest pain, shortness of breath, polyuria, polydipsia, heat or cold intolerance, fatigue, recent weight changes, rashes, lesions. Further review is otherwise negative.
REVIEW OF SYSTEMS: No CVAs, TIAs or seizures. Complains of chronic headaches. No asthma, tuberculosis, hemoptysis, productive cough or any respiratory distress. There is no congenital heart abnormality or rheumatic fever history. No palpitations or chest pain. The patient did suffer myocardial infarction in the past. At that time, he underwent a PTCA and stenting procedure to the right coronary artery system. There is no nausea, vomiting, constipation, diarrhea, melena, peptic ulcer disease, gastrointestinal problems or kidney or liver problems. There are no prostate problems. Complains of no dysuria, hematuria or frequency. There is no diabetes or thyroid problem. There are no musculoskeletal disorders or history of gout. There are no hematological problems or blood dyscrasias. There are no bleeding tendencies or thrombosis history. He has had no recent fever, malaise, changes in appetite or changes in weight.
REVIEW OF SYSTEMS: Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, visual disturbance, neck pain, chest pain, shortness of breath. All other systems are negative, except as noted in the HPI.
REVIEW OF SYSTEMS: Negative for any decrease in urine output, neck stiffness, fever, rash, difficulty with speech, swallowing or gait, diarrhea, obstipation, constipation, weight loss, weight gain, chest pain, shortness of breath or cough. The remainder of her review of systems is reviewed and negative.
REVIEW OF SYSTEMS: Constitutional: No fever or weight loss. The patient has recent fatigue. Eyes: Uses glasses. No blurry vision or loss of vision. ENT: No loss of hearing, sinus drainage, or difficulty swallowing. Cardiovascular: Chest pain as noted in the history of present illness. Palpitations as noted in the history of present illness. Respiratory: The patient has shortness of breath. No pneumonia or pulmonary problems. GI: No ulcers, diarrhea, or constipation. GU: No dysuria, frequency, or kidney problems. Musculoskeletal: No joint pain, arthritis, or muscle pain. Skin: No rash, lesions or itching. Neurologic: No stroke, seizure, or nerve damage. Psychiatric: No depression, mood swings, or other mental disorder. Endocrine: The patient with diabetes. No hypo or hyperthyroidism. Hematologic: No anemia, thrombocytopenia, or bleeding disorders.
REVIEW OF SYSTEMS: At this time, the patient denies fever or chills, although complains of malaise. HEENT: Head: The patient denies headaches or dizziness. Eyes: The patient denies diplopia, scotomata, eye pain, eye discharge, photophobia, or exophthalmos. Ears: The patient denies otalgia, otorrhea, otorrhagia, tinnitus, or vertigo. Nose: The patient denies epistaxis or rhinorrhea. Mouth: The patient denies bleeding gingivae, ulcerations, glossodynia, or dysgeusia, although complains of xerostomia. Throat: The patient denies sore throats or hoarseness. Cardiovascular: The patient denies chest pain, palpitations, syncope, night cramps, or orthostasis. Respiratory: The patient denies cough, sputum production, hemoptysis, dyspnea, wheezing, pleurisy, or hiccups. Gastrointestinal: The patient complains of xerostomia. The patient denies odynophagia, dysphagia, hematemesis, melenemesis, abdominal pain, abdominal fullness, hematochezia, melena, pruritus, or jaundice. Genitourinary: The patient denies flank pain, dysuria, stranguria, hematuria, or pyuria. Endocrine: The patient denies polydipsia, polyuria, or polyphagia. She does complain of lethargy and denies hyperactivity, denies galactorrhea, gynecomastia, or flushing. Hematology/Immunology: The patient denies pallor, pica, spontaneous or easy bruising and/or bleeding, lymph node swelling and/or pain, recurrent infections, or Raynaud phenomenon. Muscles: The patient complains of weakness, although denies myalgia. Joints: The patient denies arthralgia and/or arthritis. Neurologic: The patient denies headache, loss of consciousness, or seizure. Dermatologic: The patient denies hyperpigmentation, rash, or photosensitivity.
REVIEW OF SYSTEMS: She has hypertension, obesity, hypothyroidism, and hypercholesterolemia as mentioned. She had some stomach pain earlier, now feels better after having bowel movement this evening. She denies difficulty eating, chewing, or swallowing. She denies headache, nausea, vomiting, chest pain, shortness of breath, or abdominal pain.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Positive for fever, chills. She denies any night sweats or any significant weight loss.
HEENT: She complains of facial swelling, especially around the periorbital region and her lips, with crusting and serosanguineous discharge.
SKIN: She has macular lesions on her back, legs, and arms.
RESPIRATORY/CARDIOVASCULAR/GASTROINTESTINAL: She denies any cough, dysphagia, sore throat, any chest pain, shortness of breath, or palpitations. She denies any nausea, vomiting, diarrhea, or constipation.
GENITOURINARY: She denies any hematuria or dysuria. The patient is gravida 2, para 1. She is currently 6 weeks’ pregnant by ultrasound.
MUSCULOSKELETAL: She denies any myalgias, any deformities.
NEUROPSYCHIATRIC: She denies any depression, any suicidal or homicidal ideation, any headaches, or any history of Bell palsy.
REVIEW OF SYSTEMS: The patient denies any nausea, vomiting, headache, diarrhea, constipation, fits, pains, or seizures. She does admit to generalized weakness and poor appetite and also impaired memory.
REVIEW OF SYSTEMS:
GENERAL: No weight change, change in appetite, thirst, fever or chills.
HEENT: No headache or blurred vision.
CARDIOPULMONARY: No chest pain, palpitations or shortness of breath.
GASTROINTESTINAL: No anorexia, nausea or vomiting.
GENITOURINARY: No dysuria or pyuria.
ENDOCRINE: No goiter, lethargy or heat/cold intolerance.
HEMATOLOGY/ONCOLOGY: No pallor, bruising or bleeding.
MUSCULOSKELETAL: No change in strength. No swelling.
NEUROLOGIC: No headache or loss of consciousness.
PSYCHIATRIC: No change in personality, affect or depression.
REVIEW OF SYSTEMS: HEENT: She has eyeglass and dentures. Hearing is poor. Respiratory: She has history of cough and wheezing on and off. No hemoptysis. Cardiovascular: She used to get chest pain and CHF and cardiac arrhythmia as above, including atrial and ventricular. She has pacemaker now. GI: Appetite normal. Bowels constipated. No hematemesis or melena. She has diverticulosis of the colon. Genitourinary: She has some incontinence and also history of UTI. Musculoskeletal: She has chronic low back pain due to disk disease. Nervous system: Recent stroke as above. Endocrine system: Diabetes type 2, does not require medication, controlled with diet. Blood sugar goes high only when she is on steroids or IV high-concentrated glucose. She has hypothyroidism, on replacement. She has cholelithiasis, asymptomatic, did not require surgery. She has also atrophic left leg muscle.
REVIEW OF SYSTEMS: Constitutional: Denies fever or weight loss. Eyes: Denies acute vision changes or eye pain. ENT: Denies hearing changes or difficulty swallowing. Cardiac: Denies chest pain, edema or orthopnea. Respiratory: Denies dyspnea, cough or wheeze. GI: Admits to abdominal pain per HPI. GU: Denies dysuria or hematuria. Musculoskeletal: Denies joint pain or swelling. Skin: Denies rash or lesion. Neurologic: Denies seizures, blackout, numbness or focal weakness. Psychiatric. Admits to depression as per HPI. Endocrine: Denies polyuria or polydipsia. Hematologic: Denies blood clots or easy bleeding. Allergy: Denies hives or allergic reaction.
REVIEW OF SYSTEMS: Endocrine: History of adult onset diabetes and hyperthyroidism. Pulmonary: She denies any recent history of pneumonia, asthma, or tuberculosis. Cardiac: History of hypertension, hyperlipidemia. History of severe coronary artery disease and anterior wall MI. She denies any present history of PND or orthopnea, scarlet or rheumatic fever. Gastrointestinal: Status post cholecystectomy and colectomy secondary to diverticular disease. She denies any present difficulty with her bowel function. She denies any history of jaundice, hepatitis or cirrhosis of the liver. Genitourinary: History of stress incontinence, otherwise, unremarkable. Musculoskeletal: History of arthritic knee, status post left total knee replacement. Neurological: History of depression and anxiety. Recent psychiatric illness at admission.