Neurological: No dizziness or syncope. Denies gait disturbances or coordination problems. Denies falls or seizures. Denies numbness or tingling. Denies changes in memory or thinking patterns. Skin: No history of skin cancer. Denies rashes or sores. Patient reports dryness which he has treated with Dove skin lotion. Denies pruritus, swelling or bruising. Hematologic: No bleeding disorders or history of blood transfusion. Denies excessive bruising, anemia, or lymphadenopathy. Endocrine: Denies polyuria, polydipsia, or polyphagia. Patient denies intolerance to heat or cold. Patient denies changes in skin or hair texture. Allergic/Immunologic: Denies environmental, food, or drug allergies. No known immune deficiencies. Denies asthma, HIV or chronic infections. OBJECTIVE DATA: Physical Exam: Vital signs: B/P 119/72; P 82 and regular; T 98.6; RR 16; O2 100% on room air; Wt: 155 lbs.; Ht: 6’1”; BMI 20.4 General: JS is a well-developed, well-nourished Caucasian adult male who appears to be in no apparent distress. He is alert with linear thought process and fluent speech. HEENT: Head: Skull is normocephalic, atraumatic. No masses or lesions. Eyes : PERRLA, +direct and consensual pupil response. EOM intact, 20/20 vision bilaterally without correction. Fundoscopic exam normal, vessels intact, optic disc with clear margins. Ears : Bilateral external ears no lesions, masses, drainage or tenderness. Tympanic membranes intact, pearly gray, no bulging, no erythema, and landmarks appreciated bilaterally. Hearing intact bilaterally. Nose : No nasal flaring, no discharge, no obstruction, septum not deviated. Turbinates pink and moist. No polyps or lesions bilaterally. Nares patent with no edema or erythema. Throat: Oropharynx clear and mucosa moist. No erythema or exudate. Uvula midline, palate rises symmetrically. Mouth: No lesions, no thrush. Moist mucous membranes. Healthy dentition present. Tongue midline. Neck: +tightness, + tenderness. Full range of motion with difficulty. Trachea midline. No masses. Thyroid and lymph nodes not palpable. Chest/Lungs: Thorax non-tender with symmetric expansion. Respiration regular and unlabored, without cough. Tactile fremitus equal bilaterally and greater in upper lung fields. Breath sounds clear with adventitious sounds. All lung fields with resonant percussion tones.
Heart: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops. Apical pulse not visible. Apical pulse barely palpable. JVP appears to be approximately less than 6 cm with HOB elevated to 45 degrees. No carotid bruits or JVD appreciated. Peripheral Vascular: Pulses 2+ bilateral pedal and 2+ radial bilaterally. No pedal edema. Popliteal pulses 2+ bilaterally. Abdomen: Abdomen round, soft, and non-tender without rash, palpable mass or organomegaly. Active bowel sounds. Tympany over most quadrants with scattered areas of dullness noted upon percussion. No abdominal bruits. Genital/Rectal: Adequate tone, no masses noted, eternal genitalia intact. Musculoskeletal : Normal passive and active ROM in upper and lower extremities. No focal joint inflammation or abnormalities appreciated in upper and lower extremities.
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- Summer '15