HEENT No changes in vision or hearing he does wear glasses for myopia his last

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 for myopia, his last eye exam was 6 months ago. No glaucoma, diploplia, floaters, excessive tearing, or photophobia. Denies ear infections, tinnitus, or ear discharge. He reports his sense of smell is intact, and denies epistaxis and sinus infections. His last dental exam was 2 years ago, denies oral lesions, gingivitis, or gum bleeding. Denies difficulties swallowing. Neck: denies pain, swelling, or injury. Respiratory: denies cough, denies shortness of breath, and dyspnea. Cardiovascular (CV): Denies chest pain and palpitations. Gastrointestinal (GI): Denies abdominal pain, nausea and vomiting. No changes in bowel pattern, has 1 bowel movement every day. Genitourinary (GU): denies dysuria, dribbling, or changes in frequency. Musculoskeletal (MS): denies history of trauma or fractures, no limitations in range of motion, denies pain or discomfort. Psychiatric: Denies anxiety or depression, denies history of mental illness, denies suicidal ideation. Neurological: Denies syncope, dizziness, and paresthesias. Denies headaches. No changes in memory, thinking patterns, or personality. No gait disturbance, denies fall and seizure history. Endocrine: Reports hypogonadism, on testosterone replacement therapy. Allergic / Immunologic: No known allergies, denies immune deficiencies. Objective Data:
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Physical Exam: Vital Signs: BP: 120/80, right arm, sitting, regular size cuff; Temp: 97.9 orally; P: 68 and regular; RR: 14 and unlabored; WT: 220 lbs; HT: 5’10”. General: AAO X 3, NAD, well-nourished and groomed. HEENT: PERRLA, EOMI, Oropharynx clear. Neck: No swelling, carotids with no bruit, no JVD. Chest / Lungs: CTA, good bilateral air entry, chest expansion equal and symmetric. Heart / Peripheral Vascular: regular heart rate and rhythm, no murmur detected, peripheral pulses palpable. Abdomen: No rebound tenderness, no organomegaly, bowel sounds positive and normoactive X 4 quadrants. Genital / Rectal: Circumcised, no abnormalities noted, no masses. Musculoskeletal: Well developed, symmetric muscles, normal gait, muscle strength 5/5 all groups, good range of motion. Neuro: Cranial Nerves II – XII grossly intact. Skin / Lymph Nodes: No edema, clubbing, discoloration, or cyanosis noted. No palpable nodes detected. Assessment: Lab Tests and Results: CBC: WNL SpO2: 98% on Room Air. Diagnostics: Lab: Radiology: CXR: Clear ECG: Normal Sinus Rhythm Differential Diagnosis: Basal Cell Carcinoma Atypical Moles Seborrheic Kratoses Cutaneous tags Pityriasis Rosea Melanoma Diagnoses / Client Problems: 1. Hypogonadism 2. Erectile Dysfunction Plan: Continue current medication regimen, continue healthy and active lifestyle. Discussion: Cherry angiomas are noncancerous skin growths made up of blood vessels, they usually develop on the trunk, the cause is unknown, but they tend to be genetic, and are common
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after the age of 30 (MedlinePlus, 2017). According to Ball, Dains, Flynn, and Solomon, these types of lesions may occur on the skin of healthy adults, and are considered expected findings (2015). Cherry angiomas appear as tiny bright ruby-red, round papules that may become brown
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