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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 enlargementSkin- No rashes, pruritis, or jaundice.Head- No headaches or dizzinessEyes- No vision changes or painEars- No tinnitus or changes in hearingNose- Some recent congestion and rhinitis. No epistaxis.
Mouth/Throat- No throat soreness and dryness. No oral sores or dysphagia.Neck: No history of pain or injuriesBreasts: No lump, lesion or drainageRespiratory: Shortness of breath aggrevated by walking and talking, cough present with hemoptysis and green sputumCardiovascular: No history of arrhythmias, orthopnea, palpitations and chest painGastrointestinal: No nausea, vomiting or abdominal pain; bowel movement are normalGenitourinary: No dysuria or incontinenceMusculoskeletal: No limitation in range of motion; no history of trauma or fracturePsychiatric: No history of anxiety, depression or delusion; Denies occurrence of suicidal thoughtsNeurological: No history of headaches, syncope, seizures or dizzinessSkin: no lesions or rashesHematologic: No bleeding disorders; no history of blood transfusions
Endocrine: No hormone therapy, denies excessive thirst or sweatingAllergic/Immunologic: No known allergiesOBJECTIVE DATAPhysical exam:Vital Signs: b/p: 128/70: pulse: 82; Temp: 100.9oral. RR: 20 O2 SATS: 89%, labored; Ht: 5’9’’ ; Wt: 210 lbsGeneral: 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 polypsNeck: No bruits or JVD; tonsils not enlarged, no thyroidomegaly orthyroid masses.