Symptoms Check Up. Pt. Currently

¶ … Symptoms Check up. Pt. currently taking birth control pills (Yasmine), Zyrtec. Allergies: Penicillin Pt hx: 35-year-old female. Denies tobacco use. Occasional alcohol use. Surgery hx: Gastric band 2007, C-section 2007, D&C after miscarriage 2006, C-section 2004, tonsillectomy 1981 Medical history: Denies history of DM, CVD, asthma, seizures, head injuries, back injuries, chronic stomach problems. Admits history of HTN. GU and MS histories negative. Today's Exam: A&OX3. Alert, cooperative, dress appropriate, behavior appropriate. Affect: Appears frustrated. Hygiene: Extremely clean, clothing clean and neat. No odors noted.

Vital signs: T=98.8; P=72; R=15; BP=118/72; Ht.=68 inches; Wt.= 229 lbs. Pain Scale: (0-10) Grade= 2 Skin Color/texture: pink, soft, dry, cool Turgor: Brisk. Returns to place in less than 2 seconds. No tenting. Nevi: 3mm brown nevus on left cheek, 2mm brown nevus on left breast, 5mm brown nevus on right breast, 1mm brown nevus on interior right elbow- all borders regular, all color uniform Nail beds are pink, no clubbing of fingers. No edema noted. Small skin tags on eyelids, neck, and underside of upper arms.

Hair is blonde, full, evenly distributed, medium texture. One tattoo on left shoulder. Single piercings in both ears, right nipple. Head & Neck Scalp is pink without lesions or tenderness. Head is symmetrical and facial features are well spaced. Nose midline with pinak and dry nasal mucosa. Septum normal. Sinuses upon palpation are non-tender. Trachea is midline. Lymph nodes are non-palpable. Full ROM of neck. Eyes Eyes are slightly asymmetrical- right eye approximately 5mm higher than left eye. No lid lag. No leasions or drainage. Conjunctivae are pink and moist.

Sclera is clear, moist, and white. Cornea is smooth, moist, and clear. Iris is green and clear. There is no eythema, edema, or tenderness in the lacrinal area. PERRLA (4mm). Visual acuity (Snellen chart) without correction. Right eye: 20/100; left eye: 20/100. Both eyes: 20/100. Ears No leasions, includes, or drainage of ears noted bilaterally. Repeated 4 of 6 letters/numbers whispered at 4 feet from right ear. Repeated 6 of 6 letters/numbers whispered at 4 feet from left ear. Mouth & Pharynx Words spoken clearly. Lips pink, moist, symmetrical, with some evidence of chapping.

Tongue is pink, moist, midline, with one lesion (subject reported biting tongue when asked about the lesion). Buccal mucosa intact, pink, and moist. 31 teeth are present, and appear well kept- top left incisor removed. Uvula midline and soft and hard palates rise symmetrically. Tonsils and adenoids removed. Pharynx is midline. Neuro Alert and oriented to time, place, and person. Gait smooth. Somewhat agitated. Answers questions appropriately. Distinguishes between sharp and dull touch and warm and cold temperatures. Lungs & Thorax AP diameter to transverse diameter 1:2.

Chest rises and falls symmetrically without retractions, bulges at the ICSs or use of accessory muscles. Skin.