States caliber of urinary stream is adequate. Denies any hesitancy or dribbling. G/U (General) Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure Sexual habits - Active Interest - Women Function - Adequate Satisfaction - Adequate Use of birth control methods - Condoms HIV exposure – None Male G/U Discharge from or sores on penis; testicular pain/masses Denies any discharge from or sores on penis or testicular pain/masses. Female G/U Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP Vaginal discharge; itching; sores; lumps Menopause; hot flashes; post- menopausal bleeding; This section does not apply to my male patient. Peripheral Vascular Claudication; leg cramps; varicose veins; hx of blood clots Denies any claudication, leg cramps, varicose veins or hx of blood clots. Musculo- skeletal Muscle or joint pain; joint stiffness 1. Location – R knee 2. Quality – Joint Pain 3. quantity/severity – Pain scale 3-4/10 4. Timing – Pain only during exercise. 5. Setting – Exercising/Gym 6. Remitting/exacerbating factors - Exercise 7. associated manifestations – None. Neuro Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; Bilateral hand tremors r/t caffeine intake. 6
involuntary movements Denies any pain. Heme Hx of anemia; easy bruising or bleeding; blood transfusions Denies hx of anemia, bruising or bleeding or any blood transfusions. Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size Denies of any heat or cold intolerance, excessive sweating, polydipsia, polyphagia, polyuria, or glove or shoe size changes. Psych Nervousness/anxiety; depression; memory changes; suicide attempts Denies any nervousness/anxiety, depression, memory changes, or suicide attempts. General Findings and Physical Exam General Observations Does patient appear to be their stated age? Yes Level of consciousness AAOx4. GCS 15. Skin color Skin is pink, warm, dry and intact. Color pink. Pigmentation in relation to ethnicity appears normal. Non-tenting skin turgor also noted. Eczema rashes noted to bilateral upper eyelids, anterior neck, top of bilateral hands, bilateral inner elbow/arms, and bilateral popliteal areas. Nutritional status Nutritional status appears adequate. Denies any 7
nausea, vomiting or diarrhea. Patient states eats 3 square meals a day with no change in diet. Posture and position Pt in supine position. No postural abnormalities noted. Obvious physical deformities No obvious signs of physical deformities noted. Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Patient has steady gait with ambulation. No use of assistive devices. Full ROM of joints noted. No involuntary movement seen. Facial expression Patient has a neutral facial expression at this time. Pt able to smile and frown without effort. No asymmetry noted.
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- Spring '16
- Shelley Ashby