HPI:
here for clearance for jail. Patient has no specific complaints
ROS:
Negative for vomiting; negative for significant head trauma. 10 point review of systems performed and is negative.
Physical Exam:
General: well developed patient in no distress
HEENT: no icterus, oropharynx clear, extraocular muscles intact.
Cardiovascular: regular rate and rhythm
Respiratory: normal respiratory effort,
Abdominal exam: Soft non tender. No rebound or guarding.
Neurological: moves all extremities well, appropriate for age
Skin: warm, well perfused, no rashes
Psych: normal
Extremities: no injuries
Medical Decision Making: Patient here for medical clearance. Ok to book. No specific acute medical concerns at this time.