PRIMARY CARE NEW PATIENT HISTORY AND PHYSICAL

PRIMARY CARE NEW PATIENT HISTORY AND PHYSICAL


CHIEF COMPLAINT:
 
HPI:
 


 
PAST MEDICAL HISTORY:
 
PAST SURGICAL HISTORY: 
 
PAST PSYCHIATRIC HISTORY:
 
FAMILY HISTORY:
  Father
  Mother
  Siblings

SOCIAL HISTORY:
  Education:
  Occupation:
  Living arrangements:
  Diet/Exercise:
  Tobacco:
  ETOH:
  Illicit Drug Use:
 
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):
 
     Active Outpatient Medications                          Status
=========================================================================





******************************************************************
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: 
 Temperature:
 Weight: 
 Temperature: 
 Pain:
  

GENERAL:  Pleasant yo 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.  Pulses are 2+/4.
RESPIRATORY: CTA bilat.
ABD: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.

Labs:

ASSESSMENT AND PLAN:

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

HEALTH CARE MAINTENANCE:
colon cancer screening:
Immunizations:
DRE/PSA:

Clinical Reminders:

DISPOSITION/FOLLOW-UP:
PRIMARY CARE NEW PATIENT HISTORY AND PHYSICAL


CHIEF COMPLAINT:

HPI:




PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

PAST PSYCHIATRIC HISTORY:

FAMILY HISTORY:
Father
Mother
Siblings

SOCIAL HISTORY:
Education:
Occupation:
Living arrangements:
Diet/Exercise:
Tobacco:
ETOH:
Illicit Drug Use:

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):

Active Outpatient Medications Status
=========================================================================





******************************************************************
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:
Temperature:
Weight:
Temperature:
Pain:


GENERAL: Pleasant yo 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. Pulses are 2+/4.
RESPIRATORY: CTA bilat.
ABD: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.

Labs:

ASSESSMENT AND PLAN:

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

HEALTH CARE MAINTENANCE:
colon cancer screening:
Immunizations:
DRE/PSA:

Clinical Reminders:

DISPOSITION/FOLLOW-UP:

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