She denies nocturia incontinence or change in color

She denies nocturia, incontinence, or
change in color of urine. She is sexually active with multiple
partners. She uses oral contraceptive. She has no known history of
STI. Her Pap smears have always been normal in the past. No
pregnancies. LMP was two and a half weeks ago. She has a
menses that last five days and is a normal flow.

REVIEW OF SYSTEMS (CONT…)

Nose/Mouth/Throat : Denies sinus problems, dysphagia, nose
bleeds, or discharge, dental or gum disease, hoarseness, or throat
pain

Breast : Completes SBE. Denies lumps, bumps, discharge or
dimpling

Heme/Lymph/Eno : Denies HIV. Denies bruising, blood
transfusion history, night sweats, swollen glands, increase thirst,
increase hunger, cold or heat intolerance

REVIEW OF SYSTEMS (CONT…)

Musculoskeletal: Denies back pain, joint swelling, stiffness or
pain, fracture history, or osteoporosis

Neurological: Denies syncope, seizures, transient paralysis,
weakness, paresthesia, or black out spells

Psychiatric : Denies mood changes, depression, anxiety, sleeping
difficulties, suicidal ideation, or attempts

PHYSICAL EXAMINATION

Weight: 135 lbs. BMI: 22.5 Temp: 98.7 BP: 116/6 Height: 5ft 5in
Pulse: 66 RR: 12

General Appearance: Healthy appearing adult female in no acute
distress. Alert and oriented x four; answers questions appropriately.

Skin: Skin is pink, warm, dry, clean and intact. No rashes or lesions.

PHYSICAL
EXAMINATION(CONT
…)

HEENT: Head is normocephalic, atraumatic and without lesions; hair
evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or
scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with
positive light reflex; landmarks easily visualized. Nasal mucosa pink;
normal turbinates. No septal deviation. Neck: Supple. Full ROM; no
cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.