Denies family hx of breast cancer. Respiratory: + for occasional cough. Denies hemoptysis. Denies exposure to TB.Last CXR 2013. States he gets short of breath at times when climbing stairs around campus. Denies cyanosis, wheezing or sputum productionCardiovascular/Peripheral Vascular: Denies chest pain or discomfort. Denies palpitations or chest tightness. Denies history of abnormal heart rhythms or murmurs. Denies history of heart studies or EKG. Denies high blood pressure. Denies orthopnea. Exercises three days a week for twenty minutes. Denies bruising easy or inflammation of veins. Gastrointestinal: Denies appetite changes. + heartburn with spicy foods. Denies dysphagia, heartburn, nausea, vomiting or hematemesis. + constipation occasionally. Denies diarrhea, change in stool color or shape. Denies hemorrhoids. + flatulence. Denieshepatitis or jaundice. Denies sigmoid/colonoscopyGenitourinary: Denies dysuria, flank or suprapubic pain. + frequency. Denies urgency, nocturia, hematuria, or hesitancy. Denies polyuria. Denies edema to face. Denieshernias. Denies penile discharge.Musculoskeletal: Denies history of arthritis, gout, trauma or fractures. Denies joint swelling or redness. Denies limited ROM. Denies back pain. States no difficulties with exercising. States neck becomes stiff with onset of headaches. Psychiatric: Denies history of depression, suicidal or homicidal ideations. Deniesmood changes. + difficulty concentrating during headaches. Denies nervousness. Denies irritability or sleep difficultiesNeurological: Denies syncope, seizures, or tremors. Denies numbness or tingling.Denies weakness or paralysis. Denies recent falls or abnormal movementsSkin: + dry skin. Denies rashes or itching. Denies history of skin cancer or lesions. Denies clubbing or cyanosis of nails. Hematologic: Denies history of blood transfusions, clotting disorders or easy bruising. Denies sickle-cell anemia, or any other anemiasEndocrine: Denies thyroid enlargement or tenderness. Denies heat or cold intolerance. Denies change in facial or body hair. + dry skin. Denies cracking. Allergic/Immunologic: Denies allergies or frequent infections. Denies recent infections. Denies history of HIV/AIDS or STDs. OBJECTIVE DATA: Physical Exam:Vital signs:Temp: 98.0 oral; HR 78 and regular; R 20 and unlabored; B/P 128/62 manual, right arm, sitting. O2 sat 100% RA. Height 6’2 Weight 185 BMI 23.8General: RD is a pleasant, well-developed black male appearing younger than stated age.Sitting in chair in no apparent distress. He is alert and oriented x 3. Cooperative and answers questions appropriately. He appears well-groomed and dressed appropriately for weather. Head: Normocephalic, atraumatic. Midline of shoulders. Facial features symmetrical. Scalp moves freely. No depressions, nodules or masses. + tenderness with palpation. No nits,
NURS 6512 N-6 WEEK 9 MAIN DISCUSSION POST4parasites, lesions or scaliness. No facial or peri-orbital edema. Bilateral temporal arteries 2+ without bruits. + tenderness. No orbital or skull bruits heard with auscultation.
- Summer '15
- Headaches, denies, Denies eye pain, hernias. Denies penile