CC: “Annual Physical examination”

HPI: Pt denies any nausea or vomiting. He has no diarrhea or constipation and has not experienced any weight loss.
PMH: NC
Medications: Servent, Claritin, Flonase ,Lexapro, Occasional antacid
Surgery: None
Family hx: Fairly benign
Social hx: Denies smoking , pt is single , Never drinks ETOH
ROS:
General: Denies weight loss or gain; appetite; fever, chills, sweats; fatigue; exercise tolerance
Skin: Denies rashes, itching, bruising
Head: Occasional Tension headaches
Eyes: Denies blurry vision, double vision, scotomata, visual field defects, icterus, drainage
Ears: Denies abnormal hearing, ear pain, discharge, tinnitus, vertigo
Nose: Denies discharge, bleeding, obstruction, sensation of abnormal odors
Throat: Denies sore throat, change in voice or hoarseness, mouth pain, dental problems
Cardiovascular: chest pain or pressure, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, palpitations, claudication
Respiratory: Denies dyspnea, cough, hemoptysis, occasional wheezing when doing excersize or noxious odors , e.g perfumes
Gastrointestinal: Denies any nausea, vomiting, hematemesis, diarrhea, hematochezia, melena, constipation, change in stool
color or bowel habits, abdominal pain, jaundice
Genitourinary: Denies any discharge, lesions, dysuria, hematuria, urgency, hesitation, difficulty starting stream, leakage,
erectile dysfunction
Endocrine: Denies polyphagia, polydipsia, polyuria; goiter; tremors
Allergy/immunology: Denies urticaria, hay fever,Pt does have Mild asthma and sensitivities to foods, pollens, dander Denies
eczema,
Musculoskeletal: denies pain, swelling, stiffness, limitations of range of motion of joints
Neurologic: Denies fainting, seizures, paralysis, weakness, atrophy, spasticity, tremor, involuntary movements, gait,
incoordination, change in sensation, bowel or bladder incontinence
Psychiatric: Denies anxiety, phobias, sleep pattern, memory, judgment, delusions, hallucinations

PHYSICAL EXAM:
BP P 74 Reg. RR 14 unlabored T
Gen: Well developed, well nourished Alert, oriented x 3 and cooperative
Skin: No lesions
Lymphatics: No lymph adenopathy
HEAD: Atraumatic/normocephalic
EYES: PERRLA/EOM full; sclerae and conjuctivae clear
Fundi – normal
EARS: Tympanic membranes clear with normal light reflex
MOUTH: Edentulous with no lesions
NECK: Supple with full range of motionThyroid is normal in size and texture
CHEST: Clear to auscultation and percussion
CARDIO-VASCULAR: RRR, SI, SI, No murmurs, rubs or gallops PMI in the 5th ICS Midclavicular line No JVD or hepatojugular
reflex Peripheral pulses 2+ bilaterally with no bruit
ABDOMEN: nontender, bowel sounds normal, No aortic or renal bruits noted, No organomegaly, masses or fluid wave, Liver percussed
WNL
EXTREMITIES: No clubbing, cyanos, edema
GENITALIA: Circumcised male with no testicular masses; no hernia Present
RECTAL: Normal sphincter tone. No masses palpable, Stool guaiac Negative
NEUROLOGIC: Cranial nerves – intact, no sensory or motor deficits DTR: 2+ and symmetric throughout
LABORATORY: Reviwed recent labs WNL

IMPRESSION: Physical exam fairly benign, Pt does demonstrate mild hx of asthma since childhood , continue on Servent inhaler and
Ventolin PRN , Continue Lexapro 20 mg daily for tension headaches