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):
 
***************************************************
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:

  
**************************************************
 
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:
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):

***************************************************
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:


**************************************************

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:

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