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.
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
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.
