OK to Book Note

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.


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