Denies stu ﬃ ness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain • Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.
7/26/18, 2)20 PM Respiratory | Completed | Shadow Health Page 4 of 6 hypertension. Pt. denies CAD, CHF, PVD, angina, palpitations, tachycardia or racing heart, orthostatic changes, edema, heart arrythmias and denies sickle-cell disease. Endocrine: Pt. reports having previous diagnosis of diabetes type 2, polyuria, polyuria, polydipsia, lethargy. Pt. reposrts having oliguria, dysmenorhea, being overweight. Pt. denies changes in hair pattern, weight changes, node enlargement, breast changes, galactorhea, never been pregnant, tremors. GI: Pt. denies N/V, anorexia, diarhea, GERD, ulcers, colonoscopy, constipation, hematamesis, hematechezia, recent changes in bowel evacuation habits, dysphagia, flatulance. GU: Pt. reports increased frequency to urinate, feels thirsty all the time now, drinks a lot of fluids which doesn't seem to quench thirst. She has now been experiencing nocturia 2-3 times per night. Denies flank pain hematuria, chronic or recent UTI's, history of or knowlingly being exposde to STI's. Reports haveing three sexual partners in her life, all of which are men. Has been absinent for over a year now. Denies incontinence. Neurologic: Pt. denies changes in sensation, weakness, light-headedness, dizziness, chronic HA's, epilepsy, stroke, TIA, changes in mentation, long or short term memory, concussions, head trauma, AMS. HEENT: Pt. denies history of HA's, except for occassionally occuring when she reads too long adn resolves with 1000mg of tylenol. No vision acuity changes, except for "blurry eyes" after reading for too long. Denies other visions problems, hearing issues, nasal discharge, epistaxis, gingivitis, mouth sores. Pt. doesn't see dentist annually nor teetch professionally cleaned - hasn't been to the dentist for "years." Objective Tina is an obese 28-year-old African American woman who does not seem to be in any acute distress. Alert and oriented, sitting upright, , maintains appropriate eye contact, is conversational, and answers questions approprietly. Respiratory: Respiratory examination found Tina's chest expansion to be symetrical with respiration. Bilaterally symetrical tactile fremitous, negative broncophony anteriorly and posteriorly in all lung fields. Chest resonent when percussed, devoid of any dullness. Bilateral lower lobe expiratory wheezing both anteriorly adn posteriorly. All other lung fields clear to auscultation. No crackles, rhonchi, coarseness noted in lung auscultation. Mu ffl ed words bilaterally with prominent expiratory wheezes in the posterior lower lobes only. Spirometry yielded FVC 3.91, FEV/FVC ratio 80.56%, SaO2 97% on room air, HR 89, RR 20, BP General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on exam table. She maintains eye contact throughout interview and examination.
- Fall '15
- Pulmonary, asthma symptoms, cough, pt.