HEENT No changes in visionhearing wears glasses last eye exam was 6 months ago

Heent no changes in visionhearing wears glasses last

This preview shows page 2 - 5 out of 6 pages.

HEENT: No changes in vision/hearing; wears glasses; last eye exam was 6 months ago; no recent ear infections; no episodes of epistaxis; no sinus infection; no difficulty chewing or swallowing,no thyroid enlargement Skin- No rashes, pruritis, or jaundice. Head- No headaches or dizziness Eyes- No vision changes or pain Ears- No tinnitus or changes in hearing Nose- Some recent congestion and rhinitis. No epistaxis.
Image of page 2
Mouth/Throat- No throat soreness and dryness. No oral sores or dysphagia. Neck: No history of pain or injuries Breasts: No lump, lesion or drainage Respiratory: Shortness of breath aggrevated by walking and talking, cough present with hemoptysis and green sputum Cardiovascular: No history of arrhythmias, orthopnea, palpitations and chest pain Gastrointestinal: No nausea, vomiting or abdominal pain; bowel movement are normal Genitourinary: No dysuria or incontinence Musculoskeletal: No limitation in range of motion; no history of trauma or fracture Psychiatric: No history of anxiety, depression or delusion; Denies occurrence of suicidal thoughts Neurological: No history of headaches, syncope, seizures or dizziness Skin: no lesions or rashes Hematologic: No bleeding disorders; no history of blood transfusions
Image of page 3
Endocrine: No hormone therapy, denies excessive thirst or sweating Allergic/Immunologic: No known allergies OBJECTIVE DATA Physical exam: Vital Signs: b/p: 128/70: pulse: 82; Temp: 100.9oral. RR: 20 O2 SATS: 89%, labored; Ht: 5’9’’ ; Wt: 210 lbs General: appears well groomed, Follows orders. HEENT: Pupils Equal Round Reactive to Light; no tenderness over maxillary sinuses; nasal mucosa is moist and has some clear discharge present; Oral mucosa is dry but without lesions Nose: clear thin secretions, no polyps Neck: No bruits or JVD; tonsils not enlarged, no thyroidomegaly orthyroid masses.
Image of page 4
Image of page 5

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture