PC: COMPLAINT- DURATION
HPC:
ODQ:
PMHX: HPT-, DM-, PREV SURGERY, TRANSFUSION, PREV ADMISSION
DHX: CURR MEDS, OTC, HERBAL, ALLERGIES
FHX: HPT, DM
SHX: A __OCCUPATION__, LIVES AT __LOCATION__ WITH ___, ALCOHOL, SMOKING
OE: ADULT __GENDER__ IN NO OBVIOUS RESP DISTRESS NOR PAIN, NOT PALE, NOT JAUNDICE, AFEBRILE, HYD FAIR
RR: CHEST EXPANSION IS ADEQUATE AND SYMMETRICAL, AE ADEQUATE BIL, BS VESICULAR NO ADDED SOUND
CVS: S1 + S2 NO MURMUR
ABD: FULL, MWR, NON TENDER, NO MASSES NO ORGANOMEGALY
CNS: GROSSLY INTACT, GCS 15/15 CONSCIOUS AND ALERT, ORIENTED TO TIME PLACE AND PERSON
