Chief Complaint: Annual Physical

 

HPI:

 

NM is a 16yo African American Male with PMH Myopia (with corrective lenses) who presents today for his Annual Physical. He reports that he is feeling healthy and well, and has not had any ER visits, hospitalizations, or other interim history since last visit 1 year ago. Patient is in the 11^th grade and reports that his grades are typically B+. He reports that he sleeps “at least 8h per night” and that his diet is “mostly healthy,” reporting consuming a lot of fruits and drinking a lot of water. He exercises 5 days weekly between sports and running. He enjoys playing basketball with his friends, riding bikes, and playing online video games. Patient denies tobacco use or vaping. Admits occasional EtOH use saying “3 or 4 beers whenever there is a party,” which he reports is approximately every 2 weeks. Admits weekly marijuana use, reporting smoking one marijuana cigarette every Friday. Patient states that he is not yet sexually active with others, but identifies as male and is interested in female partners only. Patient states he feels safe in his home and environment and is not experiencing any physical, verbal, or sexual abuse. Denies feelings of helplessness, hopelessness, depression, passive or active SI.  He reports that he was seen by Dentistry November 2019 and Ophthalmology May 2019. He denies any acute complaints at this time. Denies fever, chills, nausea, vomiting, unintentional weight loss, night sweats, chest pain, SOB, abdominal pain. Patient reports that he did not receive the flu shot this year though he would like to.

 

PMH: Myopia

 

PSH: None

 

Medications:

Multivitamin PO qd

 

Immunizations: Up to date. Patient would like influenza vaccination at today’s visit.

 

Allergies: None

 

Social History:

Living Situation – Lives in an apartment with his mother and brother

Occupational – Student

Sexual History – Not sexually active. Identifies as Male. Interested in Female partners only.

Smoking/EtOH/Drugs – Patient denies current or past tobacco smoking. Admits occasional EtOH use drinking 3-4 beers every 2 weeks. Admits weekly marijuana use smoking one marijuana cigarette every Friday.

 

Family History:

Maternal Grandmother, Living HTN, HLD

Maternal Grandfather, Deceased, HTN, HLD, DM2, MI

Mother, Living

Father, Unknown

Brother, Living

 

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 : Admits corrective lenses. Denies visual disturbances, fatigue, photophobia, pruritus, lacrimation, Last Eye Exam: 05/2019, Dr. Jacob

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: 11/2019, Dr. George

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

Breast : Denies lumps, nipple discharge, pain

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

Genitourinary : Denies change in frequency, urgency, hesitancy, nocturia, polyuria, oliguria, dysuria, change in urine color, incontinence, flank pain

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 37.1C

BP 106/62

P 58bpm

RR 12 breaths/min

SpO2 100% RA

Ht: 71in. Wt: 140 lbs. BMI: 19.5 kg/m^2

General Survey : 16yo Male, 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.

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.

 

Genitourinary : Uncircumcised male; prepuce easily retractable. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally; testes smooth bilaterally. Epididymis nontender. No inguinal or femoral hernias. Tanner Stage V.

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:

NM is a 16yo Male with PMH Myopia (with corrective lenses) presenting for Annual Physical. His vital signs and physical exam findings were unremarkable. He has no acute complaints at this time.

#Annual Physical/Health Maintenance

– Procedures: N/A

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

– Diagnostic Imaging: N/A

– Immunizations: Influenza Vaccination given. Meningococcal B Vaccination given.

– Cont. Multivitamin PO qd

– Counseling on EtOH and Marijuana use performed

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student