Complete Hp Doc

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