Burning Click or tap here to enter text Hematuria Click or tap here to enter

Burning click or tap here to enter text hematuria

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Burning Click or tap here to enter text. Hematuria Click or tap here to enter text. Polyuria Click or tap here to enter text. Nocturia Click or tap here to enter text. Incontinence Click or tap here to enter text. Other: Click or tap here to enter text. Stress Denies, reports low stress level Anxiety Not knowing what is going on with his chest Depression Click or tap here to enter text. Suicidal/Homicidal Ideation Click or tap here to enter text. Memory Deficits Click or tap here to enter text. Mood Changes Click or tap here to enter text. Trouble Concentrating Click or tap here to enter text. Other: Click or tap here to enter text. GYN Rash Click or tap here to enter text. Discharge Click or tap here to enter text. Irregular Menses Click or tap here to enter text. Dysmenorrhea Click or tap here to enter text. Amenorrhea Click or tap here to enter text. LMP: Click or tap here to enter text.
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Itching Click or tap here to enter text. Foul Odor Click or tap here to enter text. Contraception Click or tap here to enter text. Other: Click or tap here to enter text. O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings.
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Body System Positive Findings Negative Findings General None noted Patient is well groomed, pleasant, appropriate speech, makes good eye contact Skin None noted Skin warm and dry to the touch, no tenting. No scars, skin intact, no rashes. Fingernails and toenails inspected, no cyanosis visualized. No visible abnormal findings of the face. HEENT None noted Head and neck is symmetrical, no swelling visualized. No visible abnormal findings visualized of the face. Respiratory Fine crackles in right and left posterior lower lobes. Chest is symmetrical Breath sounds clear in anterior lobes. No shortness of breath visualized. Neuro None noted Alert and oriented x4, moves all extremities without difficulty. Cardiovascular PMI displaced laterally, brisk and tapping less than 3 cm; Bruit present to right carotid artery +3 thrill; S3 noted in mitral area, presence of gallops on heart auscultation; Right side carotid bruit. Blood pressure (LA) 146/88, (RA) 146/90; HR 104. Dorsalis pedis arteries: right amplitude 1+, diminished or barely palpable, left amplitude 1+, diminished or barely palpable. Tibial arteries: right amplitude 1+, diminished or barely palpable, left amplitude 1+, diminished or barely palpable. Popliteal arteries: right amplitude 1+, diminished or barely palpable, left amplitude 1+, diminished or barely palpable. Chest is symmetric with no visible, abnormal findings. S1 and S2 auscultated. JVP 4 cm or less above the sternal angle. Capillary refill < 3 seconds to all extremities. Brachial, radial and femoral pulses no thrill +2. Left carotid no thrill or bruit present. No edema to bilateral lower extremities. EKG: Regular sinus rhythm, no ST elevation.
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