PRIMARY CARE ESTABLISHED PATIENT HISTORY AND PHYSICAL

PRIMARY CARE ESTABLISHED PATIENT HISTORY AND PHYSICAL


CHIEF COMPLAINT:
 
HPI:

PMH problem list:
  
ROS:
-General: Denies wt. changes, fever/chills, fatigue.
-HEENT:  Denies any changes in vision, nasal discharge/epistaxis, 
 sore throat/hoarseness or hearing problems. 
-CV: Denies chest pain, dyspnea, palpitations, edema.
-Pulmonary: Denies cough, hemoptysis, wheezes, SOB.
-G.I: Denies anorexia, N/V/D, abd. pain, constipation, heartburn.
-GU: Denies urinary symptoms at this time. Denies erectile dysfuntion.
-MS: Denies Decreased ROM, swelling, pain. 
-Neuro: Denies weakness, numbness, HAs, seizures, dizzines/vertigo. 
-Skin: Denies rashes, erythema, skin breakdown, itching.


ALLERGIES:  Patient has answered NKA

MEDICATIONS:
Active Outpatient Medications (including Supplies):
 
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MEDICATION RECONCILIATION:
    Reviewed medications with patient, including over-the-counter
and herbals.  
    Medications reconciliation was performed with the following 
results: 
    The patient was provided with a list of his/her medications? 
Yes
     If a medication list was not provided, please give the reason:

  
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PHYSICAL EXAM:
   
 Blood Pressure: 
 Heart Rate: 
 Respiratory Rate: 
 Weight: 
 Temperature: 
 Pain: 
  

GENERAL:  Pleasant 46yo white male.  NAD. 
HEENT: TMs with sharp light reflex bilaterally. PERRLA. Sclera white,
conjunctiva non-swollen.  Nares are patent, no exudates.  Nasal mucosa 
is non-swollen and red.  Throat is non-swollen, no pnd.  Uvula moves midline. 
NECK: Supple, no bruits or masses. No cervical lymphadenopathy. 
CARDIOVASCULAR: RRR, S1S2. No MRG  Radial, brachial, femoral, DP and TP pulses 
are 2+/4. 
RESPIRATORY: CTA bilat. 
ABDOMEN:  Active sounds in all quads.  No bruits, masses, or organomegaly. 
Nontender. 
GU: External genitalia normal looking.  Sphincter tone is normal.  Prostate is 
smooth, small, no nodules. 
MUSCULOSKELETAL:  MAE.  FROM.  Strength is = side to side in the UE and LE. 
SKIN: Warm and dry. 
NEURO: OX3.  CN II-XII intact.  DTRs 2+/4 all around. 
PSYCHIATRIC:  Alert, interactive.  Good eye contact.  Appropriate responses. 
 
ASSESSMENT AND PLAN:

  Pt verbalized understanding of instructions and states no further questions. 
  RTC for worsening of the above problems or for new problems.

I have discussed the following with the patient
   Labs:
   X-rays: 
   Pathology results:
   Not applicable


HEALTH CARE MAINTENANCE:
Colon CA screening:
Immunizatons:
DRE/PSA:

Clinical Reminders:

DISPOSITION/FOLLOW-UP: