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