chief complaint
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Right foot pain, fever, nausea
Shift Assessment
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...
Review of Systems
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Head: Reports headaches that occur weekly with reading in the past year.
The headache lasts a few hours and is relieved with acetaminophen and
sleep. Headaches are described as a "tight and throbbing feeling behind
the eyes." Denies head and neck trauma. Ears: Denies difficulty hearing,
tinnitus, ear pain, and discharge. Eyes: Complains of blurred vision
associated with "reading and studying," which has worsened over the past
few years. No visual acuity testing since childhood. Does not wear
corrective lenses. Reports eye itching associated with exposure to cats.
Denies discharge and pain. Nose: Rhinitis and congestion related to cat
allergy. Denies sinus problems, frequent colds/infections, epistaxis, and
change in smell. Mouth: Denies dental pain or problems, oral lesions, and
dry mouth, and changes in taste. Throat and Neck: Denies sore throat,
dysphagia, and changes to voice quality. Denies goiter,
hyper/hypothyroidism. Respiratory: Denies history of pneumonia,
tuberculosis, and chronic bronchitis. Denies cough, dyspnea, current
wheezing, hemoptysis, or recent cough. Cardiovascular: Denies
palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal
dyspnea, peripheral edema, varicosities, and pain in lower extremities.
Reports no blanching in fingertips when exposed to cold. Gastrointestinal:
Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea,
constipation, changes in bowel habits, jaundice, abdominal pain, and
bloody stools. Denies gallbladder and liver disease. Reports polyphagia,
polydipsia, nocturia for the past month and polyuria for past few months.
Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Denies
history of recurrent urinary tract infections and kidney stones. Denies
vaginal discharge and vaginal itching. Menses irregular. No history of
sexually transmitted infections. No pregnancies. Musculoskeletal: Denies
history of fractures, gout, and arthritis. Denies myalgias and arthralgias.
Denies back and neck pain and trauma. Denies generalized weakness.
Does not exercise regularly. Neurological: Denies fainting, dizziness,
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Right foot pain, fever, nausea
Shift Assessment
, Give this one a try later!
...
Review of Systems
Give this one a try later!
Head: Reports headaches that occur weekly with reading in the past year.
The headache lasts a few hours and is relieved with acetaminophen and
sleep. Headaches are described as a "tight and throbbing feeling behind
the eyes." Denies head and neck trauma. Ears: Denies difficulty hearing,
tinnitus, ear pain, and discharge. Eyes: Complains of blurred vision
associated with "reading and studying," which has worsened over the past
few years. No visual acuity testing since childhood. Does not wear
corrective lenses. Reports eye itching associated with exposure to cats.
Denies discharge and pain. Nose: Rhinitis and congestion related to cat
allergy. Denies sinus problems, frequent colds/infections, epistaxis, and
change in smell. Mouth: Denies dental pain or problems, oral lesions, and
dry mouth, and changes in taste. Throat and Neck: Denies sore throat,
dysphagia, and changes to voice quality. Denies goiter,
hyper/hypothyroidism. Respiratory: Denies history of pneumonia,
tuberculosis, and chronic bronchitis. Denies cough, dyspnea, current
wheezing, hemoptysis, or recent cough. Cardiovascular: Denies
palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal
dyspnea, peripheral edema, varicosities, and pain in lower extremities.
Reports no blanching in fingertips when exposed to cold. Gastrointestinal:
Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea,
constipation, changes in bowel habits, jaundice, abdominal pain, and
bloody stools. Denies gallbladder and liver disease. Reports polyphagia,
polydipsia, nocturia for the past month and polyuria for past few months.
Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Denies
history of recurrent urinary tract infections and kidney stones. Denies
vaginal discharge and vaginal itching. Menses irregular. No history of
sexually transmitted infections. No pregnancies. Musculoskeletal: Denies
history of fractures, gout, and arthritis. Denies myalgias and arthralgias.
Denies back and neck pain and trauma. Denies generalized weakness.
Does not exercise regularly. Neurological: Denies fainting, dizziness,
