HEENT No changes in vision or hearing he does wear glasses and his last eye

Heent no changes in vision or hearing he does wear

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HEENT: No changes in vision or hearing; he does wear glasses, and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported her sense of smell is intact. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. Nares patent bilaterally. Nasal mucosa pink without rhinorrhea. No sinus tenderness. Oropharynx without erythema or exudate. Buccal mucosa intact. His last dental exam was 01/2017. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing. Neck: Plaque involvement diffusely on his central face with erythema and scaling. Diffuse involvement of his scalp and preauricular cheek. Breasts: No history of lesions, masses, or rashes. Respiratory: Breath sounds clear all fields. Diaphragmatic excursion is symmetrical CV: No chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. GI: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern. GU: No change in his urinary pattern, dysuria, or incontinence. He is heterosexual. He has not been sexually active since the death of his spouse. MS: He has no arthralgia/myalgia, no arthritis, gout or limitation in his range of motion by report. History of rotator cuff repair due to injury. © 2014 Laureate Education, Inc. Page 7 of 10
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Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. He denied suicidal/homicidal history. Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history. Integument/Heme/Lymph: Plaque involvement diffusely on his central face with erythema and scaling. Diffuse involvement of his scalp and preauricular cheek Endocrine: No endocrine symptoms or hormone therapies. Allergic/Immunologic: Has hx of allergic rhinitis OBJECTIVE DATA Physical Exam: Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 185 lbs; Ht: 6’2; BMI 21 General: A&O x3, NAD, appears mildly uncomfortable HEENT: Plaque involvement diffusely on his central face with erythema and scaling. Diffuse involvement of his scalp and preauricular cheek. Neck: Carotids no bruit, jvd or tmegally Chest/Lungs: CTA AP&L Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound Genital/Rectal: deferred Musculoskeletal: symmetric muscle development - some age-related atrophy; muscle strengths 5/5 all groups Neuro: CN II – XII grossly intact, DTR’s intact Skin/Lymph Nodes: well demarcated, raised, erythematous plaques with a white
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  • Summer '15
  • Laureate Education, Cutaneous conditions, Erythema

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