MR#

HISTORY & PHYSICAL

REFERRING PHYSICIAN:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST HISTORY Surgical:

Medical: Medications:

Allergies:

Habits:

SOCIAL HISTORY:

FAMILY HISTORY:

REVIEW OF SYSTEMS: Constitutional: No recent fevers, chills, night sweats, fatigue, chills, etc. HEENT: No earache, sinus problems, nasal congestion or drainage or epistaxis. No visual changes, infection. Skin - Breast: No rashes, inflammation or pain. Respiratory: No dyspnea, productive cough, asthma, hemoptysis. Cardiovascular: No exertional chest pain, orthopnea, palpitations, claudication or history of rheumatic fever. GI: No nausea, vomiting, hematemesis, abdominal pain, constipation, diarrhea, hematochezia, or jaundice. GU: No urinary tract infections, hematuria, kidney stones or urinary incontinence. Musculoskeletal: No arthritis, myalgias, or muscle weakness. Endocrine: No history of diabetes. No hypoglycemia or thyroid problems. No history of excessive cold, tiredness or thirst. Hematologic: No anemia, phlebitis, or bleeding problems. Neurological: No seizures, headaches, dysesthesias. Psychiatric: No insomnia, memory loss, depression, etc.

PHYSICAL EXAM General:

Vital Signs: T= ; P= , BP= , R= , Wt.= , Ht. =

Eyes: PERRLA with full ocular motion. No inflammation.

ENT: Ears and pharynx clear. No oral lesions.

Neck: No thyromegaly, lymphadenopathy. Lymphatic: No cervical axillary or inguinal lymphadenopathy.

Breast:

Skin: No rashes, inflammation or pain.

Chest: Clear lung fields with normal breath sounds.

Heart: Heart rate regular. No murmurs, rubs or gallops. Femoral and peripheral pulses are normal.

Abdomen: Normal bowel tones. No masses or tenderness. No hepatomegaly or splenomegaly.

GU:

Limbs: Full range of motion and normal strength.

Nerves: II-XII are normal and intact. Peripheral sensation is normal. Reflexes are normal.

Psychiatric: Alert and oriented. No evidence of overt depression or altered mentation.

LABORATORY:

IMPRESSION:

PLAN:

David A. Hatch, M.D.

Professor of Urology & Pediatrics

DAH:dns