Skin hair and nails denies any rashes masses or

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Skin, Hair, and Nails: Denies any rashes, masses, or lesions. Denies any changes to hair and nails. Chest and Lungs: Denies shortness of breath, dyspnea, wheezing, or coughing Cardiovascular: Has a history of hypertension. Denies any chest pain, dyspnea, palpitations, and orthopnea. Breast : No history of lumps or tumors in breast area. Denies tenderness, discharge, or pain. Musculoskeletal: Denies any other pain, weakness, joint stiffness, or other complaints. Peripheral Vasculature : Denies any pain, tenderness, discoloration, temperature change, swelling, or claudication in extremities. Lymphatic: No known lymph node enlargement or tenderness reported. Gastrointestinal: History of Gastric ulcer and GERD. Currently experiencing nausea and abdominal pain. Pain comes in sharp waves. Patient denies hematemesis, denies diarrhea or blood in her stool; however, reports constipation. Report difficulty passing gas. Reports “bloated stomach.” Patient denies any change in stool color with her last bowel movement. Endocrine: Denies thyroid enlargement or tenderness. History of hypothyroidism. Genitourinary: Denies any history of sexually transmitted infection. Denies pain, discharge, itching, or genital lesions. Denies urgency, frequency, hesitancy, dysuria, flank or suprapubic pain. Denies nocturia, hematuria, polyuria, or stress incontinence.
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Page 4 of 6 Neurologic : Denies syncope, seizures, or tremors. Denies any numbness or tingling throughout the body. Mental Status and Psychiatric: Denies any mood changes. Report “occasional sleep disturbance.” History of insomnia and depression. OBJECTIVE : Vital Signs: Pulse: 74 BP: 146/90 on right arm with patient sitting with large adult cuff. RR: 18 breaths per minute O2sat: 95% on room air Temp: 97.9 orally Ht: 5 ft 8 inches Wt: 180lbs BMI: 32.9, patient is morbidly obese General Appearance statement: 36-year-old Hispanic female, well-groomed and presents with a pleasant affect. Physical Exam: Skin, Hair, and Nails: Skin is soft, dry, without tenting. Nail beds pink without clubbing. Nails are uniform in thickness, smooth, firmly adhered to nail bed, < 2-second capillary refill. Hair is shiny with normal thickness and evenly distributed. Head & Neck: Head erect and midline. Scalp freely movable without lesions or tenderness. Scalp is dry. Facial features and expressions symmetrical when talking; assessing CN VII. No bruit present bilaterally in temporal arteries and palpable 3+ bilaterally. No tenderness or palpable lymph nodes noted. Carotid pulse palpable 3+ bilaterally. No carotid bruit auscultated bilaterally. ROM of neck and shoulders without pain or difficult; assessed CN XI during ROM. EENT: Eyebrows and lashes evenly distributed. No tearing or crusting. No redness or jaundice. Conjunctivae pink and moist. Pupils graded as 4mm constricting to 2mm.
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  • Fall '19
  •  Essential, Date of patient encounter

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