words per minute
20
DanicaStephens
00:00
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30yo f occupation c/o few days sudden onset quality pain in location that radiates somewhere. severity some number, exacerbated by this, alleviated by that. associated with abc.
ros- no changes in mood, skin, hair, weight, diet, sleep, bowel habits, urination, or temperature tolerance. denies cough, SOB, LOC, HA, fatigue, night sweats, nausea, vomiting, palpitations or chest pain.
meds-acetaminophen allergy-penicillin causes rash.
pmh-nothing much. no surgeries. lmp 2 weeks ago, 5day cycle q28, menarche 14yo. g2p2 without complications.
sh-no tobacco, etoh or illicit drug use. sexually active with 1 m partner, consistent condom use. recently traveled somewhere without immunizations.
pt in nad, vs wnl
heent nc/at, perrla, eomi, patent nares, pharynx without exudate or erythema, good dentition, sinuses nt
neck without thyromegaly or jvd. carotids 2+
heart s1s2 rrr without m,r,g
resp ctabl with normal tactile fremitus
abd bs+4q, soft, nt, nd, no organomegaly or masses
ext no clubbing, cyanosis or edema. dtr's and pulses 2+symmetric
rectal exam with fobt
urine hcg, ua and culture
cbc with diff
arthrocentesis with crystal analysis, gram stain and culture, cell count