African American a teacher parents and cousins Male sex partner financially

African american a teacher parents and cousins male

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African American, a teacher, parents and cousins, Male sex partner, financially stable, Review of Systems General: Denied weight loss/gain, no weakness, no fever not restate HPI data here . HEENT: Uses eye glasses, no eye problems No ear infections, no tinnitus, or ear discharges Sense of smell is intact, no epistaxis, occasional allergic rhinitis Denied mouth lesions, gingivitis, no dentures, no missing teeth Neck: Scaly rashes (Plagues), itchy Breasts: Bilaterally symmetrical, no discharge, no mast Respiratory: Denies dyspnea, no coughs, last PPD negative © 2014 Laureate Education, Inc. Page 2 of 7
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Cardiovascular/Peripheral Vascular: No chest discomfort, no edema, no arrhythmias, not tachycardic Gastrointestinal: Occasional heart burn, regular bowel movement, no abdominal pains, no nausea and vomiting Genitourinary: Denied any urinary retention, dysuria, No STDs history, denied incontinence, no urinary urgency, Musculoskeletal: No upper and lower extremities weaknesses, stable gait, no assistive device, no recent fall, full range of motion, no trauma Psychiatric: History of depression and anxiety, no insomnia, no history of psychosis, Neurological: Alert and oriented X 4, no confusion, no dizziness, memory is intact, no seizure disorder. Skin: Skin not intact, white patchy plagues, scaly and itchy on the neck and at the lower back, bleeds with vigorous scratching Hematologic: No history of bruising, and or bleeding, no history of blood transfusion. Endocrine: No endocrine symptoms, no hormonal therapies. Allergic/Immunologic: Endorsed seasonal allergies, no known immune deficiencies, negative HIV test in the last 3 years. OBJECTIVE DATA: Physical Exam: Vital signs: BP 125/76, Right arm, sitting, regular cuff, P 85, RR 18, T 98.7 F orally, SPO2 100%, Wt 180 lb, Ht 5ft 5in, BMI 29.95 (overweight).
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