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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 painBreast: Completes SBE. Denies lumps, bumps, discharge or dimplingHeme/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 osteoporosisNeurological: Denies syncope, seizures, transient paralysis, weakness, paresthesia, or black out spellsPsychiatric: Denies mood changes, depression, anxiety, sleeping difficulties, suicidal ideation, or attempts
PHYSICAL EXAMINATIONWeight: 135 lbs. BMI: 22.5Temp: 98.7 BP: 116/6Height: 5ft 5in Pulse:66 RR:12General 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.