| 1 |
HPI: pt reports steady cognitive decline. |
| 2 |
ROS: neg except as above. |
| 3 |
PMH: none. PMH: migraines for 10 yrs, HTN, DM, high cholesterol. PSH: none. PSH: appendectomy, cholecystectomy, C-section. All: NKA. All: penicillin - rash. Meds: vitamins, OCP. FH: noncontributory. |
| 4 |
OBGYN: G3P3, LMP 2 wks ago, nl flow, nl Pap last yr. OBGYN: menopause 5 yr ago, denies spotting, last Pap 2 yrs ago nl. |
| 5 |
Pt denies recent fever, headache, SOB, chest pain, palpitations, nausea, vomiting, changes in bowel and urinary habits, joint pain, numbness or weakness in extremities. |
| 6 |
Pt denies recent falls, head injury, LOC, spinning, imbalance, dizziness, cough, neck pain, problems with swallowing, heartburn, lightheadedness, tongue biting, incontinence, seizure. |
| 7 |
No previous episodes of chest pain. No hematemesis, no melena or hematochesia, no hemoptysis. |
| 8 |
Associated with brief jerky movements, polyuria, nocturia, polydipsia, polyphagia, dysuria, anhedonia. |
| 9 |
SH: 1 ppd x 30 yrs, no etoh rec drugs caffeine intake, works as an engineer. SH: no smoking rec drugs, drinks 2 beers daily, retired, well supported. |
| 10 |
SxH: active with GF only, uses condoms regularly. SxH: active with multiple m partners, occasional condom use, no STD, HIV testing. |
| 11 |
Pt in NAD. Pt looks anxious, tired, avoids eye contact, speaks slowly, looks threatened. Pt in distress due to SOB. VS WNL. |
| 12 |
HEENT: NCAT, PERRLA, no fundoscopic abnormalities. No conjunctival pallor, no icterus. Yellow discoloration of skin, eye conjunctiva. TM intact, no erythema or discharge. Weber midline, Rinne ac>bc. No sinus tenderness on palpation. |
| 13 |
HEENT: Mucous membranes clear, moist, no tonsillar erythema or exudates. NL dentition and gums, no ulcers or lesions. Neck is supple, no LAD. +Kernig, +Brudzinski. Thyroid is nl on inspection and palpation. |
| 14 |
Chest: On inspection effort is nl, no accessory muscle use. No peripheral stigmata of respiratory disease. No chest wall lesions or scars. No tenderness to palpation, symm expansion on palpation. Fremitus and egophony WNL. Resonant to percussion bl. CTA BL, no WRR. |
| 15 |
CVS: No JVD, no carotid bruit. PMI nondisplaced. RRR, S1S2 present, no MRG. |
| 16 |
Abd: no peripheral stigmata of GI pathology. +BS, tympanic to percussion in 4Q. Soft, NT ND, no rebound tenderness or guarding, -Murphy, +psoas, +Rovsing, +obturator, no HSM or palpable masses. No CVA tenderness. |
| 17 |
Back: no obvious deformities or signs of trauma. No spinous processes or paraspinal muscle tenderness, ROM x6. ROM limited due to pain. |
| 18 |
Extr: no edema, pulses 2+ symm bl. -Homan's sign. Knee: -Ballottement, -McMurray, -ant and post drawer tests, -varus and valgus stress tests. Shoulder: -drop arm test, open can test. |
| 19 |
MSE: AO x3, short and long memory intact, spells backwards, recalls 3 objects. |
| 20 |
Neuro: CN 2-12 grossly intact, motor 55 throughout, sensation grossly intact to sharp and dull throughout. DTR symm 2+, -Babinski bl. Gait smooth and rhythmic. Anthalgic gait. -Romberg, rapid alt movement intact. |
| 21 |
CBC-lytes. CBC with diff. UA with cytology, culture. sputum Cx and cytology. TSH, T4, B12, RPR, Beck depression inventory. pelvic exam, wet mount, Cx, rectal exam, FOBT. |
| 22 |
orthostatic VS, audiometry, evoked brain potentials, Dix-Hallpike maneuver, physical exam, pneumatic otoscopy, colposcopy, Pap smear, hysteroscopy with biopsy, Gonorrhea and Chlamydia PCR. |
| 23 |
atrophic vaginitis, endometrial carcinoma, endometrial polyp, colonoscopy, mammogram, uterine leiomyoma, polymyalgia rheumatica, fibromyalgia, celiac disease, pyelonephritis, nephrolithiasis, renal cancer. |
| 24 |
pancreatitis, cholangiocarcinoma, viral hepatitis, gastritis, cholecystitis, pulmonary embolism, pericarditis, sinusitis, tension headache, cluster headache, hypothyroidism, hyperthyroidism. |
| 25 |
community-acquired pneumonia, bronchitis, meningitis, TIA, amaurosis fugax, orchitis, epididymitis, testicular torsion, arrhythmia, diarrhea. |
| 26 |
schizophrenia, schizophreniform disorder, schizoaffective disorder, adjustment disorder, Alzheimer. |
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