DOCUMENTATION OF HISTORY AND PHYSICAL EXAM
Patient Name (Initials only) : W.F. DOB: Gender: Male Date examined: 02/04/2024
CHIEF COMPLAINT (reason
... [Show More] for the visit)
Worsening headache, facial pain and fever
HISTORY OF PRESENT ILLNESS (chronology and progression, consider context, OLDCARTS or OPQRST)
William is a 42 year old male who presents today with a 14 day history of headaches following an upper respiratory infection. William states he has had the facial pain for about 7-10 days and that the headaches are increasing in intensity. William states he has post-nasal drip which is worse at night and cloudy in nature, sinus pressure, intermittent right tooth pain and today started with right ear pain that is stabbing in nature. William also states he started with a fever today, 100 F, at home and has taken Tylenol and OTC sinus medication, without relief. William states that changing positions and sleeping are difficult, steam showers have helped alleviate some discomfort.
It is important to note that William is a newly diagnosed Type 2 diabetic with no recent follow up appointment and has a history of seasonal allergies.
PAST MEDICAL HISTORY
Psoriasis as a child
Hypertension and Hypercholesterolemia diagnosed 6 years ago Type II Diabetes Mellitus diagnosed 11 months ago
Obesity
Previous Hospitalizations/Surgery/Trauma Appendectomy at 29 years of age
Medications (prescribed/OTC/vitamins/supplements/herbal)
Metformin 500mg PO BID Simvastatin 20mg PO at bedtime Hydrochlorothiazide 25mg PO Daily Multivitamin Daily
Tylenol
OTC sinus medication
Allergies/Adverse Reactions Seasonal Allergies
Immunizations: Flu Pneumonia Tdap Zoster Covid
FAMILY HISTORY
Father-71 y/o obesity, CAD
Mother-69 y/o obesity, Hx of diabetes Brother-47 y/o obesity, diabetes Sister-39 y/o HTN
Maternal GM-Diabetes, deceased at age of 72-sepsis r/t LE amputation Maternal GF-Hx of CV disease, deceased at age of 78-MI
Paternal GM-Deceased at age of 82-MI Paternal GF-HTN, deceased at age of 80-MI
SOCIAL HISTORY
Married
No recent travel
Diet: Traditional American Diet-high in meat and carbs Smoking: previous ½ pack a day for 20 years but quit 4 years ago
Alcohol: 1-3 beers during the week and 2-4 beers on the weekends Recreational Drugs: Marijuana in high school
REVIEW OF SYSTEMS
(Use lay language when talking to patients; document in medical terms. Describe all positive and pertinent negative findings
Constitutional (fever, chills, night sweats, weight change ,fatigue, malaise, nutrition, deformities, grooming)
Positive for Fever and fatigue, negative for chills, night sweats, weight change or malaise
Eyes (vision, pain, discharge, photophobia)
Bilateral eye pain. Negative for discharge
Ears/Nose/Throat (altered sensitivity of ears or nose, tinnitus, vertigo, pain, discharge, hoarseness, bleeds, lesions)
Positive for right ear pain stabbing in nature, post nasal drip which is cloudy and causing a cough and sore throat.
Mouth / Dental (tooth decay, gum disease, last visit to dentist, speech problems, sinus drainage, taste, snoring)
Right incisor pain that comes and goes
Breast (lumps, nipple discharge, family history of breast cancer, self breast exam)
N/A
Cardiovascular (palpitation, angina, heart attack, chest pain, shortness of breath, PND, orthopnea, claudication, syncope, hypertension, cyanosis, varicosities, edema)
Shortness of breath with climbing stairs but attributes it to his weight. Negative for chest pain/discomfort, palpations.
Respiratory (asthma, dyspnea, cough/sputum, hemoptysis, TB skin test status)
Positive for cough feels it is related to his post-nasal drip.
Gastrointestinal (dysphagia, anorexia, nausea, vomiting, hematemesis, diarrhea, constipation, melena, rectal bleeding, change in bowel habits, hemorrhoids, jaundice, abdominal pain, food intolerance)
Denies problems with nausea, vomiting, constipation, diarrhea, dark tarry stools, bright red blood in stools or bloating
Genito-Urinary (dysuria, hematuria, frequency, polyuria, urgency, hesitancy, incontinence, renal stones, nocturia, infection, frequency, retention)
Denies any urinary frequency. [Show Less]