Lifestyle: BI is a native of Eastern Kentucky. He is full-time employed as an IT Network Engineer. 90% of his job is working from his home office. He lives at home with his wife and 18-year-old daughter. His other three children are away at college, yet he reports to have conversations with them almost daily. Currently, he voices lives a sedentary lifestyle but voices the desire to be more active. He denies being active in any local organizations but reports he does enjoy cross-country traveling with his spouse of 28 years when time allows. BI reports to be heterosexual and is in a monogamous relationship with his wife. He denies having any specific religious beliefs yet states he believes in God. Review of Systems: General: BI is a clean, well-groomed Caucasian male presenting to the office awake alert oriented to place time and situation. Denies any recent weight gain, appetite loss, fever, chills, or fatigue. HEENT: Denies headache. Denies hearing loss or impairments. Denies any ringing in the ears, denies discharge or recent ear infections. Denies vision loss or impairments. Denies blurred vision. Denies the use of glasses, last eye exam was one year ago. Denies any recent hearing changes. Denies discharge, ringing in the ears, or recent ear infections. Reports his sense of smell is good. Denies any nasal congestion or sinus issues. Denies any dental issues. Last dental exam was reported to be within the last six months for routine cleaning. Mucous membranes are intact, pink, clean, moist. Denies any swallowing chewing or swallowing issues. Speech is clear without hoarseness. Neck: Denies any neck tenderness. He has a full scope of movement. No thyromegaly. No carotid bruits. No masses or tracheal deviation noted.
4 Breasts: Symmetrical denies any tenderness or discharge. Respiratory: Denies any complaints of difficulty breathing denies cough, congestion or sputum productivity. Cardiovascular: Denies chest pain, palpitations, murmurs. Denies arrhythmias or edema. Hypertension is managed well with medications. Gastrointestinal: Denies nausea, vomiting, or abdominal pain. Denies constipation. Reports regular bowel patterns; last bowel movement this AM. Occasional heartburn reported which is managed well with Protonix once daily. Genitourinary: Patient reports being continent with no difficulties in voiding. Denies frequency, urgency, or discomfort during urination. Musculoskeletal: Denies weakness or fatigue. Denies any joint pain, stiffness, arthritis or arthralgia. Full ROM is noted. Psychiatric: Denies any emotional or psychiatric issues. Denies anxiety, depression, or sleep disturbances. Reports he has a good stable support system at home with his spouse and child.
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- Summer '15