74 YO Woman with an episode of confusion

Review of Systems

  • General: Has otherwise been feeling in her usual state of health. No fever, sweats, or weight change.

  • Skin: No recent skin rashes.

  • HEENT: Mild discomfort and swelling on left lateral aspect of tongue.

  • Pulmonary: No shortness of breath or cough.

  • Cardiovascular: No chest pain, palpitations or edema, no difficulty doing her usual activities.

  • Gastrointestinal: Chronic constipation which has been stable for years, no abdominal pain, nausea, or vomiting.

  • Genitourinary: No urinary frequency, hematuria, or dysuria. Episode of urinary incontinence during sleep the prior night. No episodes of urinary incontinence prior to the current episode.

  • Musculoskeletal: Mild, diffuse bilateral upper extremity discomfort.

  • Neurologic: No headache, no vision changes, no neck stiffness, dizziness, or vertigo. No weakness or loss of sensation.

  • Psychiatric: Noncontributory