General He reports mild fever and increased fatigue. Negative for chills or weight changes. Skin Negative for skin-color changes, itchiness, rashes, or bruises
HEENT
- Head Negative for headaches or head injury.
- Eyes Reports itchy eyes.
- No visual loss, blurred vision, double vision, or yellow sclera.
- Ears Reports itchy ears.
- No ear discharge or hearing loss.
- Nose Positive for itchy nose, sneezing, nasal congestion, rhinorrhea, and postnasal drainage.
- No nasal bleeding.
- Throat Positive for itchy palate.
- No sore throat or swallowing difficulties.
- Neck No neck pain or stiffness.
- Respiratory No cough, sputum production, shortness of breath, or chest pain.
- Cardiovascular Negative for edema, palpitations, chest pain, chest pressure/discomfort, SOB on exertion, or fatigue.
- Gastrointestinal No nausea, vomiting, epigastric pain, bloating, abdominal pain, diarrhea, constipation, tarry stools, or rectal bleeding.
- Urinary No dysuria, urinary frequency, urgency, blood in the urine, or abnormal urine color.
- Genital Negative for penile discharge, testicular pain, or scrotal swelling. He denies a history of STIs.
- Peripheral vascular Denies having leg cramps, swelling/tenderness in calves, or a history of varicose veins.
- Musculoskeletal No joint pain, joint stiffness, muscle pain, low back pain, or history of fractures.
Psychiatric He denies having anxiety, depressive, or psychotic symptoms. He denies having an addiction to alcohol or drug substances. No history of psychiatric admission.
Neurologic Negative for headache, dizziness, fainting, muscle weakness, constant mood changes, loss of sensation, or tingling sensations.
Hematologic Negative for bruising or bleeding. No history of anemia or blood transfusion.
Endocrine Negative for heat/cold intolerance, excessive sweating, thinning hair, polydipsia, polyuria, or polyphagia.
