Married, mother of 5, 1 deceased. Former Domestic Worker- now retired. Attends Cathedral A.M.E.

Church
Subjective
 
Patient presents to clinic for annual wellness exam. Patient reports compliance with prescribed medication but
admits she has been out of one of her blood pressure medication for about 2 weeks. She denies any side effects
related to prescribed medication. Patient also reports that she eats a healthy diet. She denies any routine physical
activity. Patient reports occasional pain in her right shoulder and lower back. She explains that her right shoulder
hurts at times from lifting her young grandchildren. She also explains that her low back hurts from standing up at the
sink for a long period of time. Patient reports that she takes Tylenol and her pain is relieved.

Review of systems:
General: No fever, chills, or weight change.
Eyes: +blind in both eyes
Head: No headaches or migraines.
Breast: No noted lumps, no tenderness, no swelling, no nipple discharge.
Chest: No cough or shortness of breath.
Heart: +high blood pressure; No heart attack, or irregular heart beat.
Gastrointestinal: No abdominal pain, nausea, diarrhea, or constipation.. Gastrointestinal: No abdominal pain, nausea,
diarrhea, or constipation.
GU: No kidney stones, urinary tract infections, or other urinary tract problems.
Gyn: No vaginal discharge, no pelvic pain.
Musculoskeletal: + low back and right shoulder pain
Skin: No rashes or other skin complaints.
Neurologic: No weakness, no stroke, no seizures, no numbness or tingling.
Psychiatric: No anxiety or depression.
Endocrine: No excessive thirst or excessive heat or cold.
Hematologic: No anemia or easy bleeding.

Objective
  Edit
General: b/f, a/o x3, well appearing, in no acute distress.
Head: Normocephalic, no lesions.
Eyes: blind in both eyes
Nose: Mucosa normal, no obstruction.
Throat: Clear, no exudates, no lesions.
Neck: Supple, no masses
Chest: Lungs CTA a&p, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Round, soft, no tenderness, no masses, BS active x4.
Back: Normal curvature, no tenderness.
Extremities: FROM, no deformities, no edema, no erythema.
Neuro: CN grossly intact.
Skin: Normal, no rashes, no lesions noted.
Assessment
  Edit
1. Wellness exam
2. Hypertension
3. Type 2 DM
4. Hyperlipidemia
5. Visual