H&P #1

Chief Complaint: Annual Physical

 

HPI:

 

SJ is a 66yo Jamaican Female with PMH HTN, HLD, DM2, and Primary Open-Angle Glaucoma who presents today for her Annual Physical. Patient reports that she has been compliant with the medications she was given for her chronic conditions. She reports that she has been testing her blood sugar three times daily before meals and that her blood sugar has been consistently in the 100s. She denies any hypoglycemic episodes. Patient reports that her diet has consisted typically of: a hard-boiled egg and a slice of whole wheat toast for breakfast, salad for lunch, and grilled chicken with plantains for dinner. She states that she has been exercising three times weekly for a period of one-hour where she will both walk and do light weight-lifting. She denies any ER visits, hospitalizations, or other interim history since her last visit 4 months ago. Denies fever, chills, nausea, vomiting, unintentional weight loss, night sweats, chest pain, SOB, abdominal pain, headache, polyphagia, polyuria, polydipsia, vision changes, or eye pain. Patient reports that she was seen by Dentistry June 2019, Ophthalmology October 2019, and Gastroenterology with Colonoscopy 2013. She states that her last mammogram was two years ago and that her last pap smear was five years ago. She denies any acute complaints at this time. Denies intimate partner violence, feelings of helplessness/hopelessness, feelings of depression. Patient reports that she did not receive the flu shot this year and that she never takes it because “it makes you sick.”

 

PMH: HTN, HLD, DM2, Primary Open-Angle Glaucoma

 

PSH: None

 

Medications:

Amlodipine 5mg PO qd

Aspirin 81mg PO qd

Atorvastatin 20mg PO qd

Latanoprost Ophthalmic 0.005% 1 gtt in eyes qd

Metformin 500mg PO bid

Multivitamin PO qd

 

Allergies: None

 

Social History:

Immigration History – Born in Jamaica. Moved to US at age 30yo.

Living Situation – Lives in a house with her husband.

Occupational – Retired. Former Elementary School Teacher

Sexual History – Sexually active with her husband. Monogamous. Denies history of STIs.

Smoking/EtOH/Drugs – Patient denies current or past tobacco smoking. Admits occasional EtOH use, 1 glass of wine every other week. Admits daily marijuana smoking x 4 years. Denies other illicit drug use.

 

Family History:

Mother, Deceased

Father, Deceased, HTN, HLD, DM2

Brother, Living, HTN, HLD

 

Review of Systems:

General : Denies fever, chills, weakness, night sweats, fatigue, loss of appetite, weight loss

Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, change in hair distribution

Head : Denies headache, trauma, unconsciousness, coma, fracture, vertigo

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation, Last Eye Exam: 10/2019, Dr. Ki

Ears : Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses : Denies discharge, epistaxis, obstruction, rhinorrhea

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, Last Dental Exam: 06/2019, Dr. Adaku

Neck : Denies lumps, swelling, stiffness, decreased range of motion

Breast : Denies lumps, nipple discharge, pain, Last Mammogram: 2017

Respiratory : Denies wheezing, hemoptysis, cyanosis, dyspnea, shortness of breath, cough, paroxysmal nocturnal dyspnea

Cardiovascular : Denies palpitations, chest pain, irregular heartbeat, edema, syncope, known heart murmur

Gastrointestinal : Denies change in appetite, abdominal pain, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool, Last Colonoscopy: 2013 – 10y Follow-Up per GI

Genitourinary : Denies change in frequency, urgency, hesitancy, nocturia, polyuria, oliguria, dysuria, change in urine color, incontinence, flank pain, dyspareunia, anorgasmia, vaginal bleeding, Last PAP: 2014

Musculoskeletal : Denies deformity, swelling, redness, weakness, muscle pain, joint pain

Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change

Hematologic : Denies anemia, easy bruising/bleeding, lymph node enlargement, history of DVT/PE

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia, dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss, asymmetric weakness

Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation, anxiety

Physical Exam:

Vital Signs :

T 37.0C

BP 128/78

P 66bpm

RR 14 breaths/min

SpO2 100% RA

Ht: 64in. Wt: 170 lbs. BMI: 29.2 kg/m^2

General Survey : 66yo female, A/O x3. NAD.

Skin : Warm and moist, good turgor. Nonicteric. No lesions, tattoos.

Nails : No clubbing, lesions. Capillary refill <2s throughout.

Hair : Average quantity and distribution.

Head : Normocephalic, atraumatic. Nontender to palpation throughout.

Eyes : No conjunctival injection, pallor, or scleral icterus. EOMS full.

Ears : Symmetrical. No lesions/masses on external ears. No discharge.

Nose : Symmetrical. No masses, lesions, deformities, or discharge. Nares patent b/l. Nasal mucosa pink and well-hydrated.

Sinuses : Non-tender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses.

Mouth : Lips pink, moist, no lesions/cyanosis. Mucosa pink, well-hydrated. No masses/lesions/leukoplakia. Palate pink and well-hydrated, intact with no lesions. Good dentition. Gingivae pink and moist without hyperplasia. Tongue pink and well-papillated. Oropharynx well-hydrated, uvula pink, midline, no edema.

Neck : Trachea midline. No masses, lesions, scars. Supple, nontender to palpation. Full range of motion. No palpable lymphadenopathy.

Thyroid : Non-tender to palpation. No thyromegaly, goiter.

Chest : Symmetrical. No deformities. No paradoxical respirations or accessory muscle use. Respirations unlabored. LAT to AP diameter 2:1. Nontender to palpation.

Lungs : Resonant to percussion throughout. Clear to auscultation bilaterally. No wheezing, rhonchi, or rales.

Breast : Symmetrical. No deformities. Nontender. No masses or nipple discharge. No supraclavicular, infraclavicular, or axillary lymphadenopathy.

Cardiovascular : S1 and S2 normal. Regular rate and rhythm. No S3, S4, splitting of heart sounds, murmurs, rubs.

Abdomen : Soft, non-distended. Non-tender to palpation throughout. No striae, caput medusa, or abdominal pulsations. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. No masses, guarding, rebound tenderness, CVAT.

Extremities/Peripheral Vascular : Bilateral upper and lower extremities symmetric in color, size, and temperature. Pulses are 2+ bilaterally in upper extremities when palpating radial pulse. DP 2+ bilaterally. PT 2+ bilaterally. No clubbing, cyanosis, stasis changes or ulcerations in bilateral upper and lower extremities.

Assessment:

SJ is a 66yo Female with PMH HTN, HLD, DM2, and Primary Open-Angle Glaucoma presenting for Annual Physical. Her vital signs and physical exam findings were unremarkable. She has no acute complaints at this time.

#Annual Physical/Health Maintenance

– Procedures: EKG

– Labs: CBC w/ Diff, CMP, HbA1c, Lipid Panel, TSH w/ Reflex T4, Vitamin B12 and Folate, Vit. D 25-OH, UA

– Diagnostic Imaging: Bilateral Mammogram, DXA

– Immunizations: Patient refused Influenza Vaccination, Pneumococcal Vaccination, Zoster Vaccination.

– Given prior history of abnormal PAP test, will perform PAP Smear with HPV co-testing at 2wk follow-up

– Cont. Multivitamin PO qd

#HTN

– Refill Amlodipine 5mg PO qd

– Refill Aspirin 81mg PO qd

#HLD

– Refill Atorvastatin 20mg PO qd

#DM2

– Refill Metformin 500mg PO bid

#Primary Open-Angle Glaucoma

– Refill Latanoprost Ophthalmic 0.005% 1 gtt in eyes qd

 

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student