History and Physical 1

Identifying Data:  

Full Name – AG 

Sex – Female 

Date of Birth – xx/xx/1962 

Date & Time – 5/5/21 

Location – Far Rockaway   

Race – AA 

Source of Information – Self, Reliable  

Source of Referral – Self  

Chief Complaint: chest pain for 3 weeks and several recent falls. 

History of Present Illness:  

56 year old African American female with a past medical history of hypertension, hyperlipidemia, Multiple sclerosis, asthma, and vitamin D deficiency presents to the clinic complaining of chest pain for 3 weeks. She says the pain is intermittent and describes it like a dull sensation to the center of her chest. Patient says the pain does not radiate. She says the pain started on its own and is worse with certain movement and worse on inspiration. At its worse, she rates the pain as a 7/10. She has been taking Tylenol with mild relief. She also says that 3 days she fell while walking and hit her chest, and one day ago she fell and hit her head. In the clinic she has a swollen right eye. She denies any loss of consciousness, dizziness, or feeling of lightheadedness. She denies any change in vision but says her head and chest are tender to touch. She says both the chest pain and recent falls have not happened in the past. She has associated inspirational and positional chest pain and pain to touch of her head, chest and right eye but denies any excess sweating, dizziness, radiating arm pain, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, fevers or chills. She denies any recent travel or sick contacts.  

Past Medical History:  

Present Illnesses – 

• HTN 

• HLD 
• Asthma 
• Vitamin D deficiency 
• MS 
• Anemia 

• Back pain 

Past illnesses, Childhood illnesses – N/A 

Immunizations – up to date 

• Flu shot oct 2020 

Screenings – 

• Pap smear 2018: says she no longer needs one 
• Mammogram 2/2019 and 9/2020 
• Patient is due for a colonoscopy 

Surgical history – None documented, denies any blood transfusions 

Medications:  

• Acthar 80 unit/ml Gel 1ml injection 
• Ibuprofen 800mg tablet PRN 
• Amlodipine 5mg 1 tablet QD 
• Toprol XL 50mg extended release tablet QD 

• Cetirizine HCL 10 mg tablet QD 
• Flonase suspension PRN 
• Ondansetron HCL 8mg tablet QO PRN 
• Aspirin 81mg QD 
• Lipitor 20mg QD 

• Albuterol nebulizer PRN TID 
• Advair inhaler 1 puff BID 
• ProAir 2 puffs PRN every 4 hours 
• Cholecalciferol 50MCG QD 

Allergies: 

• Diovan-rash 
• Avelox-rash 
• Bactrim-rash 
• Erythromycin- nausea 
• Shellfish-rash 

• Penicillin-nausea 
• Levaquin-anaphylaxis 

Hospitalizations: 

• 7/1/2017: for MS flair up and shortness of breath 
• 8/27/2017: MS flair up and UTI 

• 1/2018: MS flair up and UTI 
• 6/2018: MS flair up and UTI 
• 9/2018: MS flair up and hypertensive crisis 
• 5/2018: Pneumonia  

Family History:  

• Father: deceased due to cardiac arrest at age 69 
• Mother: deceased due to cancer at age 73 

Social History:  

• AG is a married female who lives with husband 
• Habits: former smoker (used to smoke 1 PPD, last use was 10 years ago). Patient denies any alcohol use or ilicit drug use. 

• Travel: none 
• Diet: eats 3 well balanced meals a day, with occasional fast food use 
• Exercise: walks every day to work 
• Occupation: receptionist 
• Safety: admits to wearing a seat belt 

• Sleep: 7 hours a night 

Sexual history: 

• Patient is sexually active with husband. She does not use contraceptive or condoms. Denies ever being tested for STDs 

Review of Systems  

• General: 2 recent falls. Denies fevers, chills, weight loss, sweats, fatgiue, change in appetite  

• Skin, hair, nails: mild bruising and swelling on right eye. Denies changes in hair texture, sweating, rashes, or lesions 
• Head: headache and pain on the area of fall. Positive trauma. Denies dizziness and lightheadedness. Denies vertigo, syncope or LOC 
• Eyes: bruising, swelling and pain on right eye. Denies contacts or glasses. No change in vision, photophobia, or injection. Does not recall last eye exam. 
• Ears: denies loss of hearing, discharge, tinnitus or hear aid use 
• Nose/sinus: denies discharge, bleeding or obstruction 

• Mouth and throat: denies lesions, bleeding gums, sore throat, changes in voice, difficulty swallowing. Last dental exam was 1 year ago.  
• Neck: denies swelling or lumps. Thyroid is midline. FROM. No stiffness. 
• Breast: denies lumps, nipple discharge, or pain. Last mammogram was 9/2020 
• Pulmonary: denies shortness of breath, wheezing or cough 
• Cardio: admits to center chest pain, pain with palpation. Denies palpitations, swelling of ankles, syncope, murmur, or diaphoresis 

• Abdominal: denies changes in appetite, abdominal pain, N/V/D, constipation, hemorrhoids, rectal bleeding, or excess flatulence and eructation.  
• GU: denies urinary frequency, urgency or dysuria. No change in color of urine or excess odor 
• Sexual history: as mentioned above 
• Menstrual history: Patient went through menopause started at age 52. Denies any vaginal discharge, postcoital bleeding, or dyspareunia. LMP: 5 years ago 
• Obstetrical: patient has no children.  

• MSK: pain to chest where she fell. Denies any other muscle pain, deformity or redness. Denies arthritis 
• PVS: denies intermittent claudication, varicosities, edema or color change 
• Heme: history of anemia, well controlled. Denies easy bruising or bleeding. No lymph node enlargement or history of DVT/PE 
• Endocrine: denies polydipsia, polyphagia or polyuria 
• Nervous: denies seizures, LOC, sensory disturbance, ataxia, change in cognition or memory 

• Psych: denies depression, anxiety, and has never seen a mental health professional.  

Physical  

Vitals: BP: 150/90, HR: 84, RR: 15, Temp: 97.5F, Wt: 175, Ht: 64, BMI: 30.04, O2 sat: 99% on room air 

General:  

• Noted good lighting and draping on patient. Average size female, neatly groomed, good hygiene,  looks her stated age. Well developed and well nourished. Patient is alert and oriented to person,  place and time. Patient is in no acute distress.  

Skin, Hair, Nails and Head: 

• Skin: 1.5cm contusion to right forehead, hematoma and contusion with edema surrounding  
• Eye. Skin other size is warm and moist, non-icteric. No masses or opacities noted.  
• Hair: average texture and distribution 
• Nails: no clubbing, and capillary refill is less then 2sec throughout 

Head:  

• contusion to right head with mild tenderness to palpation. Normocephalic, and no facies noted 

Eyes:  

• Bruising and swelling to right eye. Symmetrical OU. Eyelashes and brows even distribution, no  discharge or bleeding. No excessive tearing or dryness. No strabismus, exophthalmos or ptosis  noted. Sclera is white and conjunctiva clear. Acuity is 20/20 OU. Visual fields intact, PERRLA and  EOMI with no nystagmus. Red reflex intact, cup to disc ratio is <0.5, no AV nicking or exudates.  

Ears: 

• Symmetrical with no lesions, masses or scars. No discharge or foreign bodies in ear canal.  Tympanic membrane pearly white with cone of light in normal position. Auditory acuity intact to  whisper test. Weber midline and rinne AC>BC AU.  

Nose: 

• Symmetrical no masses or step offs, no discharge. Nares patent bilaterally. Mucosa is pink and  hydrated. No discharge or foreign bodies noted. Septum is midline.  

Sinuses: 

• Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses.  

Mouth: 

• Lips : Pink, moist; no cyanosis or lesions. Non-tender to palpation. 
• Mucosa : Pink, well hydrated. No lesions, leukoplakia, or ulcerations noted. 
• Palate – nontender, Pink; well hydrated. Palate intact with no lesions; masses; scars.  
• Teeth – Good dentition, no dental caries noted 

• Gingivae: pink and moist, no masses or lesions.  
• Tongue: pink, well papillated, no masses or lesions, Non deviated.  
• Oropharynx: well hydrated, no injection, post nasal drip or exudate. Tonsils present with no  swelling or injection. Uvula is pink and midline.  

Neck: 

• trachea midline, no masses or lesions. No scars or abnormal pulsations. Supple and nontender.  FROM. No stridor, carotid pulse is 2+, no thrills or bruits. No adenopathy palpable 

Thyroid:  

• Non tender, no passes or thyromegaly.  

Thorax & Lungs:  

• Chest: mild tenderness to palpation or center chest. Symmetrical no deformities. Respirations  unlabored. No use of accessory muscles. Lat to AP diameter: 2:1.  

Lungs:  

• clear to auscultation and percussion. Symmetrical chest expansion. Tactile fremitus  throughout. No adventious sounds.  

Heart:  

• RRR, S1 and S2 intact. JVP 20cm above sternal angle. PMI in 5^th ICS. Normal rate and rhythm. No  murmurs or S3 and S4 heard. No splitting or S2 or friction rubs heard.  

Abdomen: 

• Flat and symmetrical with no masses, scars or lesions. No Striae or pulsations noted. Bowel  sounds normoactive in all quadrants. No bruit heard. Non tender to palpation, tympanic  throughout. No guarding or rebound tenderness. No hepatosplenomegaly or CVA tenderness. 

Genitalia:  

• No lesions to external genetalia, no masses or inflammation. Patient refused full genetalia  exam. No inguinal adenopathy 

Neuro: 

• Alert and oriented x 3, CN 2-12 intact. DTR 2+ throughout. Motor and sensory exam 5/5 intact. 

Peripheral Vascular Exam: 

• The extremities are normal in color, size and temperature. Peripheral pulses are 2+ bilaterally. 

MSK: 

• Mild tenderness to head and chest with palpation. No other joint or muscular pain noted. FROM  in upper and lower extremities. No evidence of spinal deformities.  

Impression: 

56 year old female comes in complaining of 3 weeks of dull localized chest pain and recent falls. On examination she has tenderness to her center chest to mild palpation, and tenderness to right head. She also had mild swelling and bruising around her right eye. History and exam is most likely consistent with costochondritis and unspecified injury of head and chest.  

Assessment & Treatment/Plan: 

1. Costochondritis: 

1. Positional chest pain for 3 weeks worse with inspiration and movement. 

2. EKG Done 
3. Results: T wave changes similar to previous EKG, no other abnormalities noted 

3. Cardiology referral given 

4. Ibuprofen 800mg PRN 

5. Follow up if symptoms worsen 

2. Unspecified injury of head  

1. ER referral given to rule out any bleed 

2. Neurology referral given 

3. Hyperlipidemia 

1. Refill Aspirin 81mg 

2. Continue Lipitor tablet 20mg  

3. Practice a low cholesterol diet and exercise.  

4. ASCVD risk 5.3% 

4. Essential HTN 

1. Continue hydrochlorothiazide 12.5mg 

2. Continue amlodipine 5mg QD 

3. Continue toprol 50mg extended release 

4. Practice low salt diet and exercise 

5. MS: 

1. Continue Acthar gel 

2. Ibuprofen tablet PRN 

3. Medical management 

6. Asthma: 

1. Continue albuterol 

2. Continue Advair 

3. Continue ProAir 

7. Vit D deficiency: 

1. Continue cholecalciferol 50mg 

8. Allergic rhinitis: 

1. Continue cetirizine PRN 

2. Continue Flonase PRN 
    

History and Physical 2

Identifying Data:  

Full Name – ML 

Sex – male 

Date of Birth – xx/xx/1988 

Date & Time – 5/10/21 

Location – Far Rockaway   

Race – AA 

Source of Information – Self, Reliable  

Source of Referral – Self  

Chief Complaint: heart burn for 3 weeks 

History of Present Illness:  

Patient is a 33 year old African American male with a past medical history of HLD who presents to the clinic complaining of 3 weeks of heartburn sensation. He says the pain started on its own, and is not associated with any specific food but comes on a few hours after he eats. He says the pain starts in his mid chest and feels “like acid is coming up my throat.” Patient denies having these symptoms prior to 3 weeks. He says that the pain is so bad at times during the night that it wakes him up. The pain comes and goes and is worst a few hours after he eats. He describes it as a sharp burning sensation, rating it a 8/10 at its worst. Patient says that the night before the symptoms were so severe that it caused him to have an episode of vomiting, which was nonbloody and nonbilious. The pain is exacerbated with laying down, and alleviated with walking, and taking long breaks between eating. He has been sleeping on 2 pillows instead of 1 for the past 2 weeks. Patient has not tried any medications for his symptoms. He denies any associated nausea, constipation, diarrhea, urinary changes, abdominal pain, headache, fever, chest pain or any other acute complaints. Patient denies any recent sick contacts or travels.  

Past Medical History:  

Present Illnesses – 

• Heart burn 

• Vitamin D deficiency 
• HLD 

Past illnesses, Childhood illnesses  

• Patient had a history of epilepsy from the age of 5-11, now resolved 

Immunizations – up to date 

• Flu shot dec 2020 

Screenings – 

• Patient denies any screenings 

Surgical history – None documented, denies any blood transfusions 

Medications:  

• Fluticasone 50MCG/ACT suspension once a day or as needed 
• Ibuprofen 800mg 1 tablet as needed, up to 3 times a day 
• Ergocalciferol 50000 UNIT capsule 1 capsule orally once a week 

• Vitamin D 400 UNIT capsule 2 capsules orally once a day 

Allergies: 

• No known drug or food allergies 

Hospitalizations: 

• Multiple hospitalizations as a child (5-11 years old) due to seizures 

• Patient unsure or exact dates. 

Family History:  

• Father: alive and weel, age 65 

• Mother: deceased at 54 years old due to Stroke and heart disease. History of HTN 

Social History:  

• ML is a single male 
• Habits: smokes 10 cigarettes daily for the past 6 years, drinks up to 6 beers every weekend, but denies any illicit drug use.  
• Travel: none 

• Diet: eats occasional fast food, but most times eats a balanced meal with protein and vegetables 
• Exercise: exercises once a day 
• Occupation: works in business 
• Safety: admits to wearing a seat belt 
• Sleep: 7 hours a night 

Sexual history: 

• Patient is sexually active with girlfriend. He uses condoms as contraception. Denies every being tested positive for an STD.   

Review of Systems  

• General:  Denies fevers, chills, weight loss, sweats, fatgiue, change in appetite  
• Skin, hair, nails: Denies changes in hair texture, sweating, rashes, or lesions 

• Head: Denies any trauma or head pain. Denies dizziness and lightheadedness. Denies vertigo, syncope or LOC 
• Eyes: Wears glasses. No change in vision, photophobia, or injection. Last eye exam was 2 years ago. Denies any lesions or trauma to the eyes. 
• Ears: denies loss of hearing, discharge, tinnitus or hear aid use 
• Nose/sinus: denies discharge, bleeding or obstruction 
• Mouth and throat: denies lesions, bleeding gums, sore throat, changes in voice, difficulty swallowing. Last dental exam was 3 year ago. Denies any erosions to the oropharynx 

• Neck: denies swelling or lumps. Thyroid is midline. FROM. No stiffness. 
• Breast: denies lumps, nipple discharge, or pain.  
• Pulmonary: denies shortness of breath, wheezing or cough 
• Cardio: denies chest pain, or pain with palpation. Denies palpitations, swelling of ankles, syncope, murmur, or diaphoresis 
• Abdominal: Positive heart burn sensation and one episode of vomiting but denies changes in appetite, nasuea, diarrhea, conspiration,  hemorrhoids, rectal bleeding, or excess flatulence and eructation.  

• GU: denies urinary frequency, urgency or dysuria. No change in color of urine or excess odor 
• Sexual history: as mentioned above 
• MSK: denies any pain to muscles or joints. Denies an deformity or redness. Denies arthritis 
• PVS: denies intermittent claudication, varicosities, edema or skin/nail color change 
• Heme: Denies easy bruising or bleeding. No lymph node enlargement or history of DVT/PE 

• Endocrine: denies polydipsia, polyphagia or polyuria 
• Nervous: denies current seizures, LOC, sensory disturbance, ataxia, change in cognition or memory 
• Psych: denies depression, anxiety, and has never seen a mental health professional.  

Physical  

Vitals: BP: 122/80, HR: 70, RR: 15, Temp: 97.5F, Wt: 275, Ht: 74, BMI: 35.30, O2 sat: 97% on room air 

General:  

• Notes good lighting and draping on patient. Large build male, neatly groomed, good hygene, looks stated age. Well developed and nourished in no acute distress. Patient is alert and ortiented to person, place and time.  

Skin, Hair, Nails and Head: 

• Skin: No rashes or lesions throughout. Skin as good turgor, and moist texture. Non icteric, no masses or opacities noted.  
• Hair: average texture and distribution 

• Nails: no clubbing, and capillary refill is less then 2sec throughout 

Head:  

• Normocephalic, atraumatic. No tenderness to palpation, no facies noted.  

Eyes:  

• No masses, lesions or bruising. Symmetrical OU. Eyelashes and brows even distribution, no discharge or bleeding noted. No excessive tearing or dryness. No strabismus, exophthalmos or ptosis.   Sclera is white and conjunctiva clear. Acuity is 20/20 OU. Visual fields intact, PERRLA and EOMI with no nystagmus. Red reflex intact, cup to disc ratio is <0.5, no AV nicking or exudates.  

Ears: 

• Symmetrical with no lesions, masses or scars. No discharge or foreign bodies in ear canal. Tympanic membrane pearly white with cone of light in normal position. Auditory acuity intact to the whisper test. Weber test midline and rinne test AC>BC AU.  

Nose: 

• Symmetrical no masses or step offs, no discharge. Nares patent bilaterally. Mucosa is pink and hydrated. No discharge or foreign bodies noted. Septum is midline.  

Sinuses: 

• Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses.  

Mouth: 

• Lips : Pink, moist; no cyanosis or lesions. Non-tender to palpation. 
• Mucosa : Pink, well hydrated. No lesions, leukoplakia, or ulcerations noted. 
• Palate – nontender, Pink; well hydrated. Palate intact with no lesions; masses; scars.  

• Teeth – Good dentition, no dental caries noted 
• Gingivae: pink and moist, no masses or lesions.  
• Tongue: pink, well papillated, no masses or lesions, Non deviated.  
• Oropharynx: no signs of acid erosion. well hydrated, no injection, post nasal drip or exudate. Tonsils present with no  swelling or injection. Uvula is pink and midline.  

Neck: 

•  trachea midline, no masses or lesions. No scars or abnormal pulsations. Supple and nontender. FROM. No stridor, carotid pulse is 2+, no thrills or bruits. No adenopathy palpable 

Thyroid:  

• Non tender, no passes or thyromegaly.  

Thorax & Lungs:  

• Chest: no tenderness to palpation. Symmetrical no deformities. Respirations unlabored. No use of accessory muscles. Lat to AP diameter: 2:1.  

Lungs:  

• clear to auscultation and percussion. Symmetrical chest expansion. Tactile fremitus  throughout. No adventious sounds.  

Heart:  

• RRR, S1 and S2 intact. PMI in 5^th ICS. Normal rate and rhythm. No murmurs or S3 and S4 heard. No splitting or S2 or friction rubs heard.  

Abdomen: 

• Abdomen is flat and symmetrical with no masses, scars or lesions. No Striae or pulsations noted. Bowel sounds are normoactive in all quadrants. No bruit heard. Non tender to light and deep palpation, tympanic throughout. No guarding or rebound tenderness. No hepatosplenomegaly or CVA tenderness. 

Genitalia:  

• No lesions to external genetalia, no masses or inflammation. No signs of hernias. No inguinal adenopathy 

Neuro: 

• Alert and oriented x 3, CN 2-12 intact. DTR 2+ throughout. Motor and sensory exam 5/5 intact. 

Peripheral Vascular Exam: 

• The extremities are normal in color, size and temperature. Peripheral pulses are 2+ bilaterally. 

MSK: 

• no joint or muscular tenderness noted. FROM in upper and lower extremities. No evidence of spinal deformities.  

Psych: 

• Appropriate mood and affect 

Impression: 

33 year old male comes in complaining of 3 weeks of heart burn sensation and one episode of emesis yesterday. Patients physical exam is normal, however history and presentation is consistent with Gastro esophageal reflux disease.  

Assessment & Treatment/Plan: 

1. GERD without esophagitis 

1. Start famotidine tablet 20 mg, 1 tablet at bedtime as needed orally QD for 30 days 

2. Patient education on lifestyle modifications such as avoiding acidic foods, spicey foods caffeine, and laying down right after meals 

3. Instructed patient to double the famotidine after 2 days if there is no relief to symptoms and follow up 1 one week to reassess 

4. Given referral for GI 

2. Vitamin D deficiency 

1. Continue taking Ergocalciferol 50000 UNIT and Vitamin D 400 Unit as prescribed.  

3. Hyperlipidemia 

1. Educate patient on keeping cholesterol low with a heart healthy Diet, and increasing exercise.  

4. Prediabetes 

1. Education on low sugar/carb diet and exercise 

5. Obesity 

1. Educate the benefits or weight loss through proper diet and exercise 

6. Nicotine dependence  

1. Smoking cessation counseling given 
    

History and Physical 3

Identifying Data:  

Full Name – TG 

Sex – female 

Date of Birth – xx/xx/1973 

Date & Time – 5/12/21 

Location – Far Rockaway   

Race – AA 

Source of Information – Self, Reliable  

Source of Referral – Self  

Chief Complaint: cough for 1 month 

History of Present Illness:  

Patient is a 48 year old female with a past medical history of asthma, sleep apnea, HTN and esophageal reflux who presents complaining of 1 month of constant cough. She says the cough started after her recent illness with COVID 19. She was diagnosed with COVID 19 on March 16^th and was then hospitalized from March 22^nd to the 30^th, where she was placed on a ventilator. She was then discharged after symptom resolution and negative testing. Patient says that since being discharged she has had this lingering cough that is nonproductive and dry in nature. She says it wakes her up at night and makes her dry heave at times. Patient also says that the cough exacerbates her asthma and has had to increase the use of her Symbicort, Ventolin and nebulizer. Due to this constant cough, patient went to the urgent care 1 week prior to this visit and was prescribed 6 days of prednisone, which she finished today and said that it helped with her symptoms. However, since using the prednisone, she has also noticed excessive vaginal discharge and white spots in her mouth that were not there before. Patient has an appointment with her pulmonologist set up for May 17^th. Due to her difficulty sleeping at night the patient says she has been using a humidifier and her CPAP machine, which has been providing relief. She has associated difficulty breathing, cough, white spots in oral mucosa and vaginal discharge, but denies any chest pain, rhinorrhea, sinus congestion, fevers or chills.  

Past Medical History:  

• Recent COVID infection 

• Cough 
• Asthma 
• HTN 
• Sleep apnea 
• Esophageal reflux 

• Cervical herniated disc 
• Bladder polyps 
• anxiety 

Immunizations – up to date 

• Flu shot Nov 2020 

Screenings – 

• Last mammogram was 1/2020 
• Last pap smear was 1/2020 
• Patient was born in El Salvadore and admits to history of BCG vaccine, states her PPDs are always positive 

Surgical history – C section 19 years ago, denies any blood transfusions 

Medications:  

• Aspirin 81mg once a day 
• Gabapentin 100mg 1 capsule TID 

• Zanaflex 4mg 1 capsule PRN or up to TID 
• Singular 10mg tablet once a day 
• Albuterol Sulfate 109MCG/ACT 2 puffs as needed every 4 hours 
• Albuterol nebulizer solution 3ml as needed every 6 hours 
• Atrovent HFA 17MCG/ACT 2 puffs four times a day 

• Zoloft 25mg once a day 
• Flonase, 1 spray each nostril once a day 
• Tessalon pearls 100mg TID 
• Felodipine 5mg ER once day 
• Losartan potassium 100mg once a day 

• Ferrous sulfate 325 MG once a day 
• Omeprazole 20mg once a day 
• Ergocalciferol 1.25mg capsule once a day 
• Diclofenac 50mg TID 
• Ambien 10mg once a day 

• CPAP machine  

Allergies: 

• No known drug or food allergies 

Hospitalizations: 

• 2002: C-section 
• March 2021: COVID 19 

Family History:  

• Father: deceased at 61 due to stroke and HTN 

• Mother: alive and has a history of HTN and heart disease.  

Social History:  

• TG is a married female with one child 
• Habits: denies smoking cigarettes, denies using drinking alcohol, denies using any illicit substances. 
• Travel: none 

• Diet: eats traditional meals of rice, vegetables, protein and beans.  
• Exercise: walks the dog, tries to take stairs 
• Occupation: home attendant 
• Safety: admits to wearing a seat belt 
• Sleep: 6 hours a night 

Sexual history: 

• Patient is sexually active with husband.. She does not use condoms or any contraception. Denies every being tested positive for an STD.   

Review of Systems  

• General:  Denies fevers, chills, weight loss, sweats, fatigue, change in appetite  
• Skin, hair, nails: Denies changes in hair texture, sweating, rashes, or lesions 

• Head: Denies any trauma or head pain. Denies dizziness and lightheadedness. Denies vertigo, syncope or LOC 
• Eyes: no glasses or contacts. No change in vision, photophobia, or injection. Last eye exam was 2 years ago. Denies any lesions or trauma to the eyes. 
• Ears: denies loss of hearing, discharge, tinnitus or hear aid use 
• Nose/sinus: denies discharge, bleeding or obstruction 
• Mouth and throat: positive white spots in oral mucosa, denies lesions, bleeding gums, sore throat, changes in voice, difficulty swallowing. Last dental exam was 2 year ago. Denies any erosions to the oropharynx 

• Neck: denies swelling or lumps. Thyroid is midline. FROM. No stiffness. No lymphadenopathy 
• Breast: denies lumps, nipple discharge, or pain.  
• Pulmonary: positive difficulty breathing and cough, denies wheezing or hemoptysis  
• Cardio: denies chest pain, or pain with palpation. Denies palpitations, swelling of ankles, syncope, murmur, or diaphoresis 
• Abdominal:  denies N/V/D, constipations, changes in appetite or abdominal discomfort.  Denies hemorrhoids, rectal bleeding, or excess flatulence and eructation.  

• GU: positive vaginal discharge. denies urinary frequency, urgency or dysuria. No change in color of urine or excess odor 
• Menstrual/OB: patient states last LMP was 1 month ago, normal flow and consistency. Patient has 1 child who is 19 years old. No pain or discomfort.  
• Sexual history: as mentioned above 
• MSK: denies any pain to muscles or joints. Denies an deformity or redness. Denies arthritis 
• PVS: denies intermittent claudication, varicosities, edema or skin/nail color change 

• Heme: Denies easy bruising or bleeding. No lymph node enlargement or history of DVT/PE 
• Endocrine: denies polydipsia, polyphagia or polyuria 
• Nervous: denies current seizures, LOC, sensory disturbance, ataxia, change in cognition or memory 
• Psych: patient has a history of anxiety which is being treated, but denies any depression or suicidal thoughts.  

Physical  

Vitals: BP: 134/70, HR: 80, RR: 16, Temp: 98.5F, Wt: 188, Ht: 63, BMI: 33.30, O2 sat: 98% on room air 

General:  

• Notes good lighting and draping on patient. Average build female, neatly groomed, good hygiene, looks stated age. Well developed and nourished in no acute distress. Patient is alert and oriented to person, place and time.  

Skin, Hair, Nails and Head: 

• Skin: No rashes or lesions throughout. Skin as good turgor, and moist texture. Non icteric, no masses or opacities noted.  

• Hair: average texture and distribution 
• Nails: no clubbing, and capillary refill is less then 2sec throughout hands and feet 

Head:  

• Normocephalic, atraumatic. No tenderness to palpation, no facies noted.  

Eyes:  

• No masses, lesions or bruising. Symmetrical OU. Eyelashes and brows even distribution, no discharge or bleeding noted. No excessive tearing or dryness. No strabismus, exophthalmos or ptosis.   Sclera is white and conjunctiva clear. Acuity is 20/20 OU. Visual fields intact, PERRLA and EOMI with no nystagmus. Red reflex intact, cup to disc ratio is <0.5, no AV nicking or exudates.  

Ears: 

• Symmetrical with no lesions, masses or scars. No discharge or foreign bodies in ear canal. Tympanic membrane pearly white with cone of light in normal position in both ears. Auditory acuity intact to the whisper test. Weber test midline and Rinne test AC>BC AU.  

Nose: 

• Symmetrical no masses or step offs, no discharge. Nares patent bilaterally. Mucosa is pink and hydrated. No discharge or foreign bodies noted. Septum is midline.  

Sinuses: 

• Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses.  

Mouth: 

• Lips : Pink, moist; no cyanosis or lesions. Non-tender to palpation. 
• Mucosa : multiple white spots noted on oral mucosa. Pink, well hydrated. No lesions or ulcerations noted. 

• Palate – nontender, Pink; well hydrated. Palate intact with no lesions; masses; scars.  
• Teeth – Good dentition, no dental caries noted 
• Gingivae: pink and moist, no masses or lesions.  
• Tongue: Some white spots noted under the tongue. pink, well papillated, no  lesions, Non deviated.  
• Oropharynx: no signs of acid erosion. well hydrated, no injection, post nasal drip or exudate. Tonsils present with no  swelling or injection. Uvula is pink and midline.  

Neck: 

•  trachea midline, no masses or lesions. No scars or abnormal pulsations. Supple and nontender. FROM. No stridor, carotid pulse is 2+, no thrills or bruits. No adenopathy palpable 

Thyroid:  

• Non tender, no passes or thyromegaly.  

Thorax & Lungs:  

• Chest: no tenderness to palpation. Symmetrical no deformities. Respirations unlabored. No use of accessory muscles. Lat to AP diameter: 2:1.  

Lungs:  

• clear to auscultation and percussion. Symmetrical chest expansion. Tactile fremitus  throughout. No adventious sounds. Good air entry bilaterally 

Heart:  

• RRR, S1 and S2 intact. PMI in 5^th ICS. Normal rate and rhythm. No murmurs or S3 and S4 heard. No splitting or S2, friction rubs, or clicks heard.  

Abdomen: 

• Abdomen is flat and symmetrical with no masses, scars or lesions. No Striae or pulsations noted. Bowel sounds are normoactive in all quadrants. No bruit heard. Non tender to light and deep palpation, tympanic throughout. No guarding or rebound tenderness. No hepatosplenomegaly or CVA tenderness. 

Genitalia:  

• White vaginal discahrge noted on genitalia exam. No other lesions or masses seen. Patient rejected full speculum exam. No inguinal adenopathy noted 

Neuro: 

• Alert and oriented x 3, CN 2-12 intact. DTR 2+ throughout. Motor and sensory exam 5/5 intact. 

Peripheral Vascular Exam: 

• The extremities are normal in color, size and temperature. Peripheral pulses are 2+ bilaterally. 

MSK: 

• no joint or muscular tenderness noted. FROM in upper and lower extremities. No evidence of spinal deformities.  

Psych: 

• Appropriate mood and affect 

Impression: 

48 year old female comes in complaining of 1 month of nonproductive cough. She states her symptoms started after a recent infection with COVID 19. She has also been having white spots in her oral mucosa and vaginal discharge. History and physical exam is consistent with post viral cough and a yeast infection.  

Assessment & Treatment/Plan: 

1. Recent history of COVID 19  

1. Continue aspirin 81mg once a day 

2. Follow up with pulmonologist on 5/17/2021 

2. Post-viral cough 

1. Continue Tessalon pearls 100mg TID 

2. Pulmonologist appointment on 5/17/2021 

3. Chest Xrayy referral given 

4. Symptomatic treatment 

3. Candidiasis 

1. Start fluconazole tablet 150mg 1 tablet today and one in 3 days 

4. HTN 

1. Continue felodipine 5MG once a day 

2. Continue losartan 100mg once a day 

3. Educate patient on heart healthy diet and exercise and BP Maintenace  

5. Obstructive sleep apnea 

1. Continue using CPAP 

6. HLD 

1. Education on low cholesterol diet and exercise 

7. Primary insomnia 

1. Continue Ambien tablet 10mg once daily or as needed 

8. Asthma 

1. Continue singular tablet 10mg once a day 

2. Continue albuterol 2 puffs as needed 

3. Continue albuterol nebulizer solution as needed  

4. Continue Atrovent 2 puffs as needed, four times a day 

5. Follow up with pulmonology  

9. Esophageal reflux disease 

1. Continue omeprazole 20mg once day 

10. Vitamin D deficiency 

1. Continue ergocalciferol 1.25mg weekly