Patient: M.B.

Subjective
CHIEF COMPLAINT(s) REASON FOR VISIT:
o Follow up on KAT scan

HISTORY OF PRESENT ILLNESS:
o 51-year-old male patient is here to follow up on his KAT scan for his
lower back. Today he is still under pain. His pain level is 6/10. He is
taking medication for the pain but he says it only works for a little bit.
The other thing he does to alleviate the pain is lying down. He denies
any chest pain or shortness of breath.

PAST MEDICAL HISTORY
o Adult medical conditions: Hypertension, diagnosed 3 years ago.
o Major childhood illnesses: mumps, chicken pox.
o Current medication: hydrochlorothiazide 25 mg/day for
hypertension.
o Surgical procedures: bilateral inguinal hernia repair at age 1
o Injuries: broken arm at age 11
o Hospitalization for the surgeries above
o Immunizations: tetanus 5 years ago, +PPD at age 10
o Allergies: Sulfa (hives)

FAMILY HISTORY:
o Father: 58, hypertension
o Mother: 50, rheumatoid arthritis
o Siblings: Brothers; 25 and 21 alive and well. Sister; 18 alive and well.
o Paternal grandfather: 85, hypertension
o Paternal grandmother: 83, osteoarthritis
o Maternal grandmother: deceased at age 81, unknown cause
o Maternal grandfather: deceased at age 84, heart attack

No history of DM, cancer, alcoholism, psychiatric illness or known genetic
illness.

SOCIAL HISTORY
o Living arrangements: divorced, lives alone
o Residence: resides in an apartment
o Sexual history: N/A
o Occupation: unemployed
o Environmental exposures: no identified harmful exposures
o No tobacco, alcohol, or other drug use
o Diet and exercise: patient maintains a good diet and gets moderate
exercise.
o Education: some high school

Patient: M.B.
REVIEW OF SYSTEMS:
o GENERAL PREVIEW:
Patient denies Weight changes, Appetite changes, Unusual
weakness, Bleeding, Recent trauma or infections, Chills, Fever
o HEENT:
Patient denies Headaches, Blurry vision, Changes in visual
acuity, Nasal congestion/ discharge, Sinus infections, Epistaxis,
Mouth sores, Loss or change of taste or dry mouth.
o NECK:
Patient denies neck pain, swellings or stiffness.
o LUNGS:
Patient denies productive or non-productive coughs, wheezing,
and shortness of breath.
o CARDIOVASCULAR:
Patient denies dyspnea on exertion, orthopnea, PND or
swelling of the lower extremities. Patient also denies
palpitations or rapid heart rate, chest pain, syncope,
intermittent claudication.
o GASTROINTESTINAL:
Patient denies nausea/vomiting, hematemesis, dysphagia,
abdominal pain, and hematochezia. Patient also denies melena,
diarrhea, constipation, alcoholic stools, and flatulence.
o GENITOURINARY:
Patient denies any recent dysuria, urine frequency, urine
hesitancy, urine urgency, urine flow being slow, urine
retention, nocturia, polyuria, dark urine, or incontinence.
o MUSCULOSKELETAL:
Patient complains of arthralgia, joint stiffness, back pain,
muscle cramps, muscle weakness, and myalgia.
o SKIN:
Patient denies any rashes, lesions, anhidrosis, bruising or
pruritus.
o ENDOCRINE:
Patient denies polyuria, polydipsia, polyphagia, weakness,
weight loss, and any history of heat or cold intolerance.
o NEURO:
Patient denies having migraines or tension headaches, blurring
vision or changes in visual acuity, diplopia, and
photosensitivity. Patient also denies any memory loss,
disorientation, syncope, dizziness, vertigo, clumsiness,
paresthesias, and loss or change of taste. Patient also denies
having any seizure, a history of sleep disturbances, unusual
emotional changes, mood swings or depression.



Patient: M.B.
Objective
VITAL SIGNS:
o BMI: 25.2
o BP: 118/80
o H: 67.00 IN
o P: 69/MIN
o RR: 18/MIN
o T: 97.4 F
o W: 160LB

PHYSICAL EXAM
o GENERAL:
General appearance; can be described as well nourished, well
developed, and in no acute distress.
o LYMPHATIC:
No abnormal neck, axillary, groin lymph nodes detected.
o HEAD:
No lesions of oral or nasal mucosa. Tympanic membranes are
intact.
o EYES:
Acuity 20/20(R); 20/20(L) visual fields. Eyes are aligned; lids,
conjunctivae and sclera are normal; pupils are 3mm and equal;
normal response to light; extraocular movements (EOM) are
intact; Fundi; sharp disc margin; no hemorrhage, no lesions, no
discharge or other abnormalities.
o EARS:
Outer ear without lesions, normal acuity, tympanic canals
normal; tympanic membrane with normal light reflex, no
erythema or bulge.
o NOSE/ SINUSES:
Nasal mucosa is normal, nasal septum is midline, no
tenderness over maxillary or frontal sinuses.
o MOUTH & PHARYNX
Normal lips, tongue, gums and healthy teeth; pharynx is
normal. Tonsils are normal.
o NECK:
Lymph nodes are normal. Neck tissue exam demonstrates no
masses, symmetrical. Trachea is midline. Thyroid is palpable
and normal.
o CHEST/ LUNGS:
Normal to inspection; respiratory effort symmetric without use
of accessory muscles.
Normal to inspection. Lung auscultation shows no wheezing,
and equal breath sounds.
Breath sounds are normal with no extra sounds.
Patient: M.B.
o CARDIAC:
Heart auscultation shows regular rates and rhythms, there are
no murmurs, gallop or rub. Normal heart sounds.

o VASCULAR:
2+ carotid pulse bilaterally- no bruits
Aortic pulsation normal, no bruits over aorta, femoral or renal
arteries
Pulses
Radial Femoral Popliteal D. Pedis P. Tib
R 2+ 2+ 2+ 2+ 2+
L 2+ 2+ 2+ 2+ 2+

No lower extremity edema, no varicosities.

o ABDOMEN:
Normal bowel sounds
No mass or tenderness found.
LIVER/SPLEEN: no hepatomegaly or splenomegaly.
Hernia checking discovers no bulging or weakness in
abdominal wall.
o MUSCULOSKELETAL:
Full range of motion and normal appearance of all joints of
upper and lower extremities.
o NEUROLOGICAL:
Mental status normal 30/30
Patient is alert and oriented.
Cranial nerves II XII are intact
Motor strength 5/5 throughout and no increased tone
Sensory function normal to light touch, vibration and joint
position sense
Coordination normal
Biceps, brachioradialis, triceps, knee, ankle reflexes 2+
bilaterally
Babinski negative, no clonus, gait normal, Romberg negative,
no pronator drift
o GENITALIA:
EXAM NOT DONE
o RECTAL EXAM:
EXAM NOT DONE
o PSYCHIATRIC:
Insight and judgment appear both to be intact and appropriate.
Mood and affect are described as normal mood and full affect.
o SKIN:
No rashes or lesions.

Patient: M.B.
Assessment
Injury to the lower spine
Hypertension is well controlled on medication.

Plan
Lumbar pain: Start patient on Ibuprofen 800 mg q 6-8 h a day.
Hypertension: Hydrochlorothiazide 25 mg/day