Daniel DeMarco                                                          H&P#3                                                 Family Medicine

 

Chief Complaint: Annual Physical

 

HPI:

 

AR is a 50yo Guyanese Male with no PMH who presents today for his Annual Physical. He reports that he feels healthy and well, has been eating a vegetarian diet for more than 2 years now, and has been exercising 4 times per week where he will go to the gym and alternate between a cardio work out and weightlifting. He denies any ER visits, hospitalizations, or other interim history since his last visit one year ago. Denies fever, chills, nausea, vomiting, unintentional weight loss, night sweats, chest pain, SOB, abdominal pain, melena, hematochezia. Patient reports that he has not seen a Dentist in “probably 5 or more years.” He denies any acute complaints at this time. Denies intimate partner violence, feelings of helplessness/hopelessness, feelings of depression. Patient reports that he did not receive the flu shot this year and that he never receives it.

 

PMH: None

 

PSH: None

 

Medications: None

 

Allergies: None

 

Social History:

Immigration History – Born in Guyana. Moved to US at age 40yo.

Living Situation – Lives in a house with his wife and child (15yo Daughter)

Occupational – Electrician

Sexual History – Sexually active with his wife. Monogamous. Denies history of STIs.

Smoking/EtOH/Drugs – Patient admits current tobacco smoking of half a pack per day. He reports he has been smoking since he was 20yo, totaling 15 pack-year history. Admits social EtOH use, 6 beers over the course of a week. Denies illicit drug use.

 

Family History:

Mother, Living

Father, Living, HTN, HLD, CVD

 

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

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

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, dyspareunia, anorgasmia, vaginal bleeding

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 36.8C

BP 162/94

P 84bpm

RR 14 breaths/min

SpO2 100% RA

Ht: 68in. Wt: 154 lbs. BMI: 23.4 kg/m^2

General Survey : 50yo 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.

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.

 

Genitourinary : Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally; testes smooth bilaterally. Epididymis nontender. No inguinal or femoral hernias.

 

Rectal and Prostate : Anus without lesions. DRE revealed normal sphincter tone without masses. Smooth, nontender prostate.

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:

AR is a 50yo Male with no PMH presenting for Annual Physical. His blood pressure was concerning for hypertension. His physical exam was unremarkable. He 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, PSA, UA

– Referrals: GI (for Screening Colonoscopy), Dentistry for Routine Care, Ophthalmology to Establish Care

– Diagnostic Imaging: N/A

– Immunizations: Patient refused Influenza Vaccination.

– Start Multivitamin PO qd

#Nicotine/Tobacco Dependence

– Extensive counseling performed. At this time, patient amenable to attempting to “cut back” on his smoking with the goal of smoking only 5 cigarettes per day rather than 10 per day.

#?HTN

– Patient will return for BP monitoring in 2wks

 

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student