RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood, reports reduce appetite. GENITOURINARY: No dysuria, last menstrual cycle started 03/19/2019, not pregnant NEUROLOGICAL: No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. Reports head ache x 3 days 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. O. Physical exam: 20 y/o Caucasian female, A/O x3, No apparent distress, 5’4”, 125 lbs, BMI-21, BP 112/74, HR 58, RR 20, SPo2 97%, oral temp 98.9. Head: Normocephalic, Eyes: PERRLA, sclera clear, Ears: Canals clear, TMs visible pearl grey in color, non-bulging, no drainage bilateral, Nose: Turbinate’s boggy, bright pink and moist, clear drainage present bilateral nares, Mouth: Oral mucosa pink moist and intact, no obvious dental caries, no missing teeth Throat: Tonsils stage 2 red beefy in color, posterior pharynx reddened with drainage clear drainage present. Neck is supple, trachea midline, submandibular, post auricular lymphedema present. Heart: regular rate and rhythm, Lungs clear throughout, equal rise and fall of chest with respirations, Abdomen -soft, flat, non-tender, Extremities: no edema, tenderness, deformity. Skin/Hair/Nails: normal turgor, color appropriate for ethnicity.
Diagnostic results : Rapid influenza swab, CBC, CMP A .
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- Summer '15
- Grandparent, Common cold, Headaches