SUBJECTIVE: Mr.xxx has multiple questions and problems.
He states that his ears may be full of wax. He uses a liquid but he still feels that he has some problems there.
Pain in his knee, especially over the patella, also when he puts pressure on it, such as kneeling. He has left knee pain when he flexes his leg at times, but this is intermittent and none of these are disabling.
He needs a refill on medications.
He also requests a complete physical examination.
He has some various reactions when he takes his blood pressures. He gets anxious, and his blood pressure stays elevated.
OBJECTIVE:
General: This is an alert and orient male aged 57.
Vital signs: Blood pressure 148/84; retake is 150/84; temperature 98.4; pulse 78; respiration 16. Weight 222 pounds. Height 5 feet 11 inches.
Skin: Warm and dry.
HEENT: Cranium is normocephalic and atraumatic. Ears have increased cerumen bilaterally.
Chest/Lungs: Clear.
Heart: Regular rate and rhythm.
Abdomen: Soft.
Extremities: No peripheral edema.
ASSESSMENT: Hypertension, obesity and hyperlipidemia.
PLAN: Refill hydrochlorothiazide and lisinopril. Add atenolol 25 mg 1 tab daily to the regimen of hydrochlorothiazide and lisinopril 40 mg. He is also taking Zocor 20 mg, and he will return for a complete physical exam. Also, the patient's ears were irrigated, and he was advised regarding his ears.We will follow up.
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SUBJECTIVE: The patient presents with a complaint of low back pain. She states that she is feeling much better. Emotionally she is in therapy. She still has a great deal of problems with family, etcetera, but it is definitely better. Regarding her complaint of low back pain, she was seen by Dr. XXX. She is taking medications. She still has sacroiliac discomfort, and we discussed this with regard to therapies.
OBJECTIVE:
Vital signs: Blood pressure 170/90; retake 160/90. Temperature 98.6. Pulse 64. Respiration 12. Weight 228 pounds.
Skin: Warm and dry.
Cranium: Normocephalic.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear.
Heart: Regular rate and rhythm.
Abdomen: Obese and nontender.
Extremities: There is no peripheral edema. The feet were examined, and they show no lesions which may be aggravated by her diabetes.
ASSESSMENT:
Diabetes mellitus, non-insulin dependent.
Obesity.
A case of chronic heart disease with status post coronary artery bypass graft (CABG).
Hyperlipidemia.
Hypertension.
PLAN: The patient's chart is not available at this time. She will return for a complete physical exam in 2 weeks, but she is having laboratory work done. We have not done this in quite a while. She is having SMA 20, with repeat UA, CBC, TSH, HbA1c in 12-hour, microalbumin done. Her medications are atenolol and lisinopril plus the medicines which I do not have listed. She will bring all her medications, and hopefully we will find her chart prior to her being examined.
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SUBJECTIVE: XXX is here for medication refill and also have her lipids evaluated. She is feeling well; there are no specific complaints at this time.
OBJECTIVE:
General: The patient is a 54-year-old white female, alert, oriented, and in no distress.
Vital signs: Blood pressure 140/80; temperature 98.6; pulse 97; respiration 16. Weight 167 pounds. Height 5 feet 3 inches.
Skin: Warm and dry.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Soft.
Extremities: No peripheral edema.
ASSESSMENT:
1. Hyperlipidemia.
2. History of fibromyalgia.
3. Lactose intolerance with irritable bowel syndrome.
PLAN: New prescription for Vytorin 10/20. She will get #30 to try, and then if no side effects such as diarrhea, she will get the 90-day supply. If that is not covered by her insurance, we will order Zocor. We need to follow. The patient is asked to return in 3 to 4 months.
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SUBJECTIVE: Mr. XXX is here for followup. He complains that he is getting severe back spasms upon rising from bed or even getting out of his chair at times. It may last 3 to 4 days where he is incapacitated. He has had at least twice in the past month, and before that he had this several times during the month. He failed to make any mention of it. The patient had no history of trauma; it is just moving from one area to another, or arising from a sitting position.
OBJECTIVE:
General: This 84-year-old gentleman is alert and oriented in no severe distress
Vital signs: Blood pressure today was 130/60, temperature is 97, pulse is 60, and respiration is 14. Weight is 190 pounds. He is 6 feet 3 inches tall.
Skin: Warm and dry.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Flat and nontender.
Extremities: There is no peripheral edema at this time.
Musculoskeletal: On examination of the spine, there is some muscle of the right lower lumbar area, but it is not tender. I am not certain if this is a normal finding in this gentleman's case. He is muscular in general.
ASSESSMENT:
1. Hypertension, with history of atrial fibrillation, diabetes mellitus, osteoarthritis, spinal stenosis, hyperlipidemia, and glaucoma.
PLAN: He has Vicodin for the severe pain. He has several conditions definitely predisposing him to these problems, one of which is his arthritis, and the other is his spinal stenosis. I will discuss this more in the future. We will follow.
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SUBJECTIVE: The patient is here for a review of her blood pressure and to review diabetic standing. She is doing quite well. Her only problem is that she is having difficulty with sleeping.
OBJECTIVE:
General: The patient is a 52-year-old white female. She is alert, oriented and in no distress.
Vital signs: Blood pressure 130/68; temperature 97.6; pulse 88; respiration 20. Weight 166 pounds. Height 5 feet 2 1/2 inches.
Skin: Warm and dry.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Soft. There is no mass nor tenderness.
Extremities: There is no peripheral edema. The patient denies any sores on her feet or any other significant changes.
ASSESSMENT:
1. Diabetes mellitus.
2. Hypertension, controlled.
3. Hyperlipidemia.
PLAN: We will continue to monitor. The patient is to return in 6 weeks or as necessary.
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SUBJECTIVE: Xxx presents with the complaint that she has had chest pain, which is oppressive, as somebody is sitting on her chest, and difficulty in getting her "ear". She says that she gets pain in the right arm and also cervical spine pain when this occurs. There is some difficulty with the history. This is because of the nature of the problem and also of the patient's prohistorian as well. This has occurred in 4 episodes, which is disconcerting. She also has abdominal pain; it is a chronic pain, which keeps her from employment. She also a right upper quadrant pain. Whether this is GI or cardiovascular remains to be seen. She was taken to the emergency room and they gave her a clean bill of health and sent her home a week ago.
MEDICATIONS:
1. Naprosyn.
2. Vicodin.
3. Voltaren.
4. Prozac.
5. Tylenol.
6. Some medications for her eyes.
She is not to take Voltaren and Naprosyn at the same time. If she does, she may have stomach problems from that. She shakes her head no, she is not taking both medications.
OBJECTIVE:
General: This is an obese 53-year-old asthenic female, alert, and in no distress at this time.
Vital signs: Blood pressure 120/90; temperature 98.6; pulse 76; respiration 16. Weight 232 pounds. Height 5 feet 1 inches.
Skin: Warm and dry.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Rounded, obese and nontender.
Extremities: There is no peripheral edema.
ASSESSMENT: Chest pain, etiology secondary to psychophysiologic reaction versus esophagitis versus cardiovascular complications.
PLAN: Repeat electrocardiogram; have cardiology re-evaluate, and consider an upper GI and esophagram to rule out any esophageal problem. I will treat the esophagus at the present time with mild antacid medication and possibly proton-pump medications to prevent her symptoms, and then await referral to cardiology. We will follow.
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SUBJECTIVE: He has no specific complaints. He has some concerns about his skin as he was a surfer and exposed to the sun. However, we examined him last year and again this year, and we will evaluate the skin areas. He has physical examination a year; he is gainfully employed, and he is a hardworking gentleman. There is a history of asthma, but he has been asymptomatic for some time. The patient is a nonsmoker, and drinks alcohol only very socially. There is no family history of chronic disease. His parents are in their 80s, living and in good health.
REVIEW OF SYSTEMS: He denies constitutional symptoms. He has gained 5 pounds over the past years. He has no fever or night sweats.
Thyroid or throat: He denies visual or hearing difficulties.
Respiratory: He does not complaint upper respiratory infections or chronic cough, etcetera. He denies shortness of breath or chest pain. There is no cardiovascular symptoms of fatigue, palpitations or chest pains either. The asthma has been asymptomatic for a long time.
Gastrointestinal: He denies nausea, vomiting, diarrhea, and constipation. There are no changes in bowel habits.
Genitourinary: There is no history of dysuria. He has occasional back aches in the past, but has been asymptomatic over the past years or so.
OBJECTIVE:
General: The patient is a healthy-appearing, good-looking 6 ft 4 in 43-year-old Caucasian weighing 187 pounds.
Vital signs: His blood pressure is 120/80; temperature 97.2; pulse 64; respiration 16. Weight 187 pounds. Height 6 feet 3 1/2 inches tall.
Skin: Warm and dry. There are no lesions of note on his back or elsewhere.
HEENT: [2:40 hyro-per-cream] normocephalic, atraumatic. Pupils round and equally reactive to light, accomodation and distance. There is increased cerumen in the right ear which will be lavaged. Contaminants were localized on the left but not on the right. Nares slight congestion. Pharynx benign.[02:59] No oral lesions.
Neck: Supple. No bruits, thyromegaly, or retinopathy. No restriction in motion.
Chest/Lungs: Symmetrical. Lungs clear to auscultation without adventitious breath sounds.
Heart: Regular rate and rhythm. No murmurs, friction, rub, or gallop.
Abdomen: Flat and nontender. No masses. No hepatosplenomegaly. No tenderness noted. There is no hernia, either ventral or inguinal.
Genitalia: Circumcised male without penile [3:24 sl circumferential?] lesions.
Rectal: Prostate is normal in size and shape, flat, nonindurated. Stool is negative for occult blood.
Musculoskeletal: Spine has no asymmetry. No paraspinal muscle splinting.
Extremities: Intact. No clubbing.
Neuro: Cranial nerves are grossly intact. Deep tendon reflexes were not tested, but the patient had no difficulty in ambulation and walking, or any other physical activities. The patient has a [3:51 sl terse?] sensorium.
ASSESSMENT: Healthy male. History of asthma, asymptomatic. History of back pain, asymptomatic. Cerumenosis in the
PLAN: Lavage of the right ear. Laboratory studies have been ordered. We will follow.
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