Short Summary Ontario System

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REVIEW OF SYSTEMS:\ GENERAL: The patient denies any general bad health lately, recent weight change, fever, fatigue or headaches. EARS, NOSE, MOUTH, AND THROAT: The patient denies hearing loss, earaches, chronic sinus problems, nosebleeds, bleeding gums, sore throat, or swollen glands in neck. CARDIOVASCULAR: The patient denies heart trouble, chest pain, palpitations, shortness of breath, or swelling of the feet, ankles or hands. GENITOURINARY: The patient denies frequent urination, burning or painful urination, blood in urine, or incontinence. SKIN: The patient denies any rashes, itching, changes in skin color, varicose veins, breast pains or breast lumps. NEUROLOGICAL: The patient denies dizziness, numbness, tingling, tremors or paralysis. ENDOCRINE:…show more content…
Blood pressure 102/70. Pulse 66. She is 132 pounds and 5’2” tall. EYES: PERRLA. Extraocular movements intact. HEAD AND NECK: Normocephalic and atraumatic. Trachea midline. Neck is supple. No evidence of masses. RESPIRATORY: Respiratory rate regular, even, and unlabored. No signs and symptoms of distress. No cough or wheeze present. SKIN: Warm, dry and intact. No open lesions to the bilateral lower extremities. No erythema, ecchymosis or rashes present. NEUROLOGICAL: Cranial nerves II through XII are grossly intact. No obvious motor or sensory deficits. Adequate sharp dull and proprioception to the bilateral lower extremities. VASCULAR: Dorsalis pedis and posterior tibial pulses 2+ bilaterally. Negative Homans sign bilaterally. MUSCULOSKELETAL: The patient reports minimal pain with palpation of the infracalcaneal heel and no pain with palpation of the posterior heel, however she does report severe pain with side-to-side compression of the calcaneus. No apparent deformity of the left lower extremity. PSYCHOLOGICAL: The patient is alert and oriented to person, place and time. Good mood and affect. She is able to answer questions

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