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REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fev=
er or
chills, no weight loss. GU: Denies pain or burning with
urination. GENERAL: No fevers. RESPIRATORY: No dyspnea or cough. CARDIOVASCULAR: No chest pain or palpitations. All other systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperat=
ure
36.4, pulse 74, respirations 16, blood pressure 120/60 and saturation is 98=
% on
room air, which is normal.
GENERAL APPEARANCE: H=
e is
alert, cooperative and denying any pain.&n=
bsp;
HEENT: Pupils react to
light. Extraocular motions are
intact. There is no nasal
discharge. Mucous membranes a=
re
moist.
NECK: Supple without
adenopathy.
LUNGS: Clear.
CARDIOVASCULAR: Regul=
ar
rate and rhythm.
ABDOMEN: Bowel sounds=
are
present. Some slight tenderne=
ss in
the epigastric and right upper quadrant area but no rebound or guarding, no
masses and no CVA tenderness.
SKIN: Warm and dry wi=
thout
rashes.
NEUROLOGIC: Motor is =
5/5.
Sensation is intact.