History and Physical - DOC by vIPDym06


									Chief complaint: []

History of present illness: [].

Review of systems:

no weight change, No History of chronic HA/migraines, denies Bleeding tendencies/Dizziness/Denies
CP/SOB/DOE/PND/ Cough/ no Hemoptysis/Heartburn/ no Nausea or Vomiting, no Diarrhea
/Constipation / Abdominal pain / no known gastrointestinal bleeding / no Black stools/ no edema / no
new skin lesions/ no rash/ no new arthralgia. no new bone pain, No recent illnesses. No history of recent

Past Medical History: [None]

Past Surgical History: [None]

[No known drug allergies. No known contrast allergy.]

Medications: I reconciled medications with the patient. Currently taking [no medications]

Social History: [Nonsmoker]

Family History: [No premature atherosclerotic coronary artery disease. No premature sudden cardiac

Physical Exam:

Vital signs: [Normal, as above. height and weight reviewed, as listed.]

Physical Exam:

General: Alert and Oriented x 4, No acute distress, pleasant and cooperative with exam
HEENT: Pupils equal, round, reactive to light, sclera anicteric, normal Conjuctiva nl oral pharynx
moist/pink, no exudates
Neck: no jugular venous distension, lymphadenopathy, bruits
Cardiovascular: Regular Rate, Rhythm, no gallops, no murmurs, no rubs, s1/s2 where normal, no S3/S4
Pulmonary: Lungs clear to auscultation bilaterally, no rhonchi, no rales, or wheezes
Abdomen: soft/non-tender/ normal active bowel sounds, no Hepatosplenomegaly, no mass, no ascites,
non palpable kidneys, no obvious bruits
Extremities:      no clubbing/cyanosis/edema/varicose veins, pulses 2+X4
Joint: - crepitus/swelling
Skin: normal exam, no rashes, no petichae
Neurological: Mental Status appears normal; she had a non-focal exam, hearing grossly intact, no tremor
EKG: I performed an EKG in cardiology clinic the date of the visit and personally reviewed the tracing.
This demonstrated []

Laboratory: I reviewed the laboratories from []

Radiology: I reviewed the []


Neurological/Psychological/Pain: []

Pulmonary: []

Cardiovascular: []

Gastroenterology/Genitourinary: []

Hematology/Oncology: []

Infectious Disease: []

Renal/electrolytes: []

Endocrine: []

Rheumatologic: []

Disposition: []


Deep Vein Thrombosis: []
Gastric Protection: []

LTC J. Steven Birchfield M.D.
Chief, Internal Medicine
DSN: 314-486-8871
(+49) 15150495110

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