Peripheral Vascular: denies any peripheral vascular problem .
Urinary: Reports burning on urination, denies back pain, frequency, blood in the urine.
GYN: Reports vaginal itching with thin, gray vaginal discharge. Reports vaginal discharge with strong foul, fishy odor; reports vaginal odor particularly strong with a fishy smell after sex, denies STDs.
Musculoskeletal: Denies joint pains, joint stiffness, or problem with joints range of motion.
Psychiatry: Denies anxiety, depression, mood changes, and mental health. Denies any suicidal ideation or attempt.
Neurological: Denies memory loss, dizziness, tingling/numbness, falls, and seizures.
Integument/Hematology/Lymph: Denies bruising easily, skin rashes, dryness, itching, skin lesions and cancer. Denies any clotting or bleeding disorders. Denies transfusion reaction.
Endocrine: Denies diabetes, thyroid problem, heat or cold intolerance.
Allergic/Immunologic: Denies allergic rhinitis, denies immune deficiencies.
OBJECTIVE DATA
Physical Exam:
General: Alert and oriented. Appeared well-groomed. Patient does not appeared to be in any acute distress. Vital signs: B/P 116/74, left arm, sitting; P 76; RR 18; SPO2 100% RA. Weight 132 pounds, BMI 20.53, Height 65 inches.
HEAD: Head round and symmetry, no lesions, bumps, nodules, or injury noted.
EENT: PERRLA, clear conjunctiva and sclera; hearing intact bilateral; TMs visualized, pearly grey; clear nasal passage, normal turbinates, septal deviation absent. Oral mucosa pink and moist .
Neck: thyroid supple, midline trachea, no thyromegaly or lymphadenopathy
Chest/Lungs: Chest wall symmetrical, no use of accessory muscles note, breath sound are clear to auscultation, no wheezing, rhonchi, or prolonged expiration noted in the upper/lower lung fields. No nipple discharges or abnormal lump noted.
Heart: S1, S2 noted with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs noted. Capillary refill normal at 2 seconds. Pulses palpable/normal at 2+. No edema noted.
Abdomen: Abdomen is soft, non-tender and non-distended. Bowels sounds are present in all 4 quadrants. No hepatosplenomegaly.
Genital: Gray, thin, watering vaginal discharge with foul fishy odor noted.
Musculoskeletal: Full range of motion present in all extremities. No varicose vein, clubbing, cyanosis, or edema present. Palpable peripheral pulses present .
Neurologic: Alert and oriented; ambulatory with steady gait. Speech clear/audible. All extremities movable. Touch sensation and two- point discrimination present and intact .
Skin: No rashes, nodes, lumps, ulcers noted. Skin moisture good and turgor is intact.