Reference no: EM133786008
SUBJECTIVE: This is a 72-year-old female with PMH of HTN, DM, seizures, fibromyalgia, asthma and arthritis presents to clinic because of ongoing cerumen impaction. c/o clogged B/L ears for the past 2 weeks Debrox drops did not work. Could not get cue tip in far enough to clean out wax post Debrox use. Patients have bilateral ear irrigation at clinic. right ear was irrigated successfully, and left ear requires further evaluation with ENT. Patients always feel fatigue, SOB in exertion NYHA III. can only walk a few feet before needing to rest. Denies cough, palpitation, nausea or vomiting, headache or dizziness.3 weeks ago, lower abdomen skin procedure done. "big hard mole" removed, bilateral lower limb swelling improved. no swelling today.
OBJECTIVE: make change when necessary
Vital Signs:Ht(without shoes) 172 cm (5'8"). Wt. (dressed) 58.51 kg (184 lbs.)(BMI: 28.0 kg/m2) BP 120/60 mmHg (right arm seated); 125/62 mmHg (left arm, seated); with wide cuff. Heart rate (HR) 70 bpm and regular. Respiratory rate (RR) 18 bpm. Temperature (oral) 97. 9°F, Spo2: 100% Room air.
HEENT: Positive for runny nose, watery eyes, and sore throat. Denies earache or dizziness.
Eyes: Vision 20/20 in both eyes. Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm. PERRLA. EOMI. Disc margins are sharp, without hemorrhage or exudate: no arteriolar narrowing or A-V nicking.
Ears: Ear canal clear bilaterally. TM clear bilaterally; bilaterally Ear good cone of light.The cone of light is at 5 o'clock in the right ear and 7 o'clock in the left ear. Rinne test: Positive bilaterally (AC > BC). Weber midline: No lateralization. Mastoid process: No tenderness noted bilaterally.
Nose Mucosa pink, septum midline. No sinus tenderness.No polyps, turbinate intact, no evidence of bleeding.
Mouth: Oral mucosa pink. The dentition is good. Tongue midline. Tonsils 1+. Pharynx without exudates.
Neck: Neck Supple. Trachea midline. The thyroid isthmus is palpable, and lobes are not felt.
Lymph Nodes: No cervical, axillary, or epitrochlear nodes.
Thorax and Lungs: Thorax Symmetric with good expansion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Respiratory: Positive for a productive cough with yellowish sputum. Denies shortness of breath (SOB).
Cardiovascular: Regular rate and rhythm, heart rate 70 bpm. Crisp S1 and S2. At the base, S2 is louder than S1. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.
Abdomen:soft, non-tender + BS, no guarding.
Diagnostics:Obtained before the diagnosis, examples: would be CBC or BMP, CXR or TSH etc.
Assessment:
Plan:
Any diagnostics ordered / planned (this would be diagnostics needed)
- Pharmacologic and Nonpharmacologic: The patient was prescribed Polymyxin B/Trimethoprim solution 1 drop q 4 hours while awake
x7 days. (also enter quantity # here if controlled substance or antibiotics)
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