D.History:The patient is a 52 year old male who came in to have an annual physical with a primary care provider. He is a police officer and is married, no kids and lives at home with 2 dogs. The patient was hospitalized at age 12 for an exploratory laparotomy after being diagnosed with internal bleeding. An appendectomy was done during the surgery. He reports moderate exercise, mostly working outside on his home farm. He is up to date on his immunizations, has regular eyeand dental exams done. He does not smoke or use other tobacco and drinks occasionally. His father passed away at age 88 with congestive heart failure. Mom is 77, still alive and doing well, living on her own. The patient’s past medical history includes hyperlipidemia, GERD, arthritis inhis spine. Medications include 40mg atorvastin nightly, 20mg omeprazole daily and 500mg naproxen PRN. Physical Exam:The patient is alert and oriented to person, place, time and situation. He is calm and cooperative with care. The patient’s skin is pink, warm and dry, no sores or open areas noted anywhere on his body. His head has no open sores, hair distribution is equal and normal cephalic.He was able to frown, smile and raise his eyebrows. There was no tenderness of pain with palpation of frontal and maxillary sinuses. TMJ was without pain or crepitus. Pupils ERRL, accommodate with exam. Visual acuity shows 20/20 eyesight and conjunctiva are white and without discharge or redness. There was no nystagmus noted with the 6 cardinal directions of gaze and the patient was able to follow the examiner’s pen. Septum clear. On exam of the mouth,
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- Fall '18