Reason for encounter- "I have a headache since yesterday morning that will not go away.” History of present illness-One day ago the patient started to have a throbbing headache and nausea, that is unrelieved by medication. GeneralE.M. is a 22-year-old female with complaints of a headache for one day, nausea, , that will not go away with medication. Patient is 5 feet 7 inches tall and weighs 118 lbs. Patient is alert and oriented x4. Patient answers questions correctly and is appropriately dressed. Patient appears to be stated age. No distress noted. Heent/ neck- Patient head is normocephalic. Frontal and maxillary sinuses are non-tender. Eyes appear to be normal appearing with no deformities or discharge noted. No nasal discharge, polyps, edema, or tenderness noted. Tonsils are not enlarged, symmetrical bilaterally. Uvula is midline. No oral ulcers or vesicles noted. No periodontal erythema, lesions or bleeding noted. Dry mucous membranes noted. No white patched noted. Patient denies swallow issues. No tenderness noted on the anterior cervical lymph nodes. Patient denies ear pain, no discharge or redness noted. Reports headache. Denies head injury Skin/Nails: Nails are intact, symmetrical, no lesions, no splitting, no clubbing, thickening, or separation. Skin color is appropriate for ethnicity, uniform, and warm to touch. Skin is soft, even, and dry. 3. Head/Face: Head is normocephalic, upright, and straight, non-tenderness, and no palpable masses. Hair is dark and long. No sinus tenderness or pressure, no popping, locking or pain in the TMJ. 4. Eyes: Eyes clear with no noted abnormality, Sclera white, conjunctiva is pink, no edema, no foreign object, no crusting. PERLLA, Corneal reflex with alignments of eyes and even gaze. Visual normal blood vessels defined optic disk, and red reflex. 5. Ears: External ear is symmetrical, color is the same as the body, no discharge, no nodules, no lesions, no drainage, non-tender, and no pain.. Canal clear, no edema, no erythema, Tympanic membrane is gray, present cone of light, clear landmarks/bones. No perforation, and no foreign bodies. Normal hearing. 6. Nose : No septum deviation, patent, light pink, no erythema, no edema, and no discharge. External lips, mouth no lesion, internal moist oral mucosa. Downloaded by Sandra Agazie (sanziehealthcare@gmail.com) lOMoARcPSD|1485752 7. Mouth/Throat: No lesion in the Lips and mouth, moist oral mucosa, no erythema. Teeth are intact with visible filings on some of the teeth. Tonsils with no erythema, no exudate, and no enlargement. Able to move tongue in different directions. Posterior pharynx and uvula are visualized and WNL. 8. Neck: No lymphadenopathy, trachea midline, and thyroid normal size with no nodules. Able to shrug shoulder. Full ROM and moderate strength 9 Denies vision changes, pain, diplopia, scotomata, lacrimation, inflammation,infection.Reports photophobia Cardiovascular- S1 and S2 Heart sounds heard are and normal. No murmurs heard at this time. Respirations- The chest is symmetrical and the anterior- posterior diameter is normal. The excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles. Lungs are clear and unlabored upon assessment. No distress noted at this time. No distention, scars, masses or rashes Abdomen- Abdomen is normal and symmetric with no scars, deformities or herniation. No tympany or shifting dullness. Liver is 12 cm at MCL, palpable spleen tip with inspiration, diffuse tenderness to palpation, no guarding, no rebound tenderness, no palpable herniation, absent shake sign, no fluid wave. Rectal- non- contributory Muscular- non- contributory Neuro- Patient is alert and oriented to person, place, time and situation. Patient denies confusion. IntegPsychiatric- non- contributory Past medical history-Patient states that the only childhood illness he had is chicken pox. Patient states that during his adult hood he has had bouts of diarrhea of unknown reasons with no further studies completed. Hospitalizations- Patient denies hospitalizations. Surgeries- Patient denies having any surgeries. Downloaded by Sandra Agazie (sanziehealthcare@gmail.com) lOMoARcPSD|1485752 Preventative health- biannual dental cleaning and dental exam; up to date on immunizations, including seasonal flu vaccine. Medications- No medications being taken right now Allergies - no known allergies occasionally Social history- Partner is a direct marketing company that publishes a variety of health-related magazines. Married with 2 children. Lives in a house in West Chester; no pets or tobacco; 1 glass of wine 3 to 4 nights weekly; sexual history: 4 partners who were all woman prior to meeting his wife at age 26; monogamous since meeting his wife Family historyMother is alive and 67 years old with no health history. Father is alive and is 68 years old with mild hypertension that is being regulated with medication. Grandparents health is unknown. Kids are 8 and 12 years
Order this paper