health insurance through his job, states he “does not eat very healthy and needs to exercise more.” He states he does not belong to a gym; he walks his dog in his neighborhood about one mile three times a week. Review of Systems: General: Feels fatigued after work, no recent weight loss or gain, no night sweats. HEENT: No vision or hearing changes, wears glasses or “readers” to read, and his last eye exam was nine months ago. Denies eye surgery, eye pain, photophobia, diplopia, floaters, cataracts, glaucoma, or excessive tearing. He denies any ear infections, tinnitus, ear drainage, or hearing loss. He has not had any recent sinus infections, episodes of epistaxis, or a history of allergic seasonal rhinitis. He denies any oral ulcers, gingivitis, gum bleeding, difficulty chewing or swallowing. He had a dental exam 1 ½ years ago and is due for a dental exam now. Neck: Denies any pain or injuries. No x-rays or imaging done. Breasts: N/A Respiratory: No cough, dyspnea, or history of pneumonia. No PPD. Chest x-ray over five years ago. Cardiovascular/Peripheral Vascular: Denies any palpitations, chest pain history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, or claudication. Last ECG done one year ago at annual physical. No other cardiac workup has been done. Gastrointestinal: No abdominal pain, nausea, or vomiting, “indigestion” controlled with tums. States he only uses tums about once a week, denies any reflux. No change in bowel pattern, has daily bowel movements, and denies any diarrhea or constipation. Genitourinary: No change in his urinary pattern or stream. No urinary hesitancy, penile discharge, or erectile dysfunction. He is heterosexual and in a monogamous relationship with his wife. Denies any history of STDs or HPV. Last testicular examination was one year ago, has had no prostate exam or PSA test. © 2014 Laureate Education, Inc. Page 2 of 5
Musculoskeletal: Denies any arthralgias, arthritis, gout, joint swelling, or trauma. He states he has full range of motion. Psychiatric: Denies any anxiety or depression. He states he is sleeping well. Neurological: Denies any numbness, tingling, weakness, syncope, or gait problems. No headaches or changes in memory. Skin: He has a “wart” in his right axilla (see HPI). Denies any sores, rashes, itching, or bruising . Denies any changes or problems with hair or skin texture.
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- Summer '15