Example

"The Works"  History and Physical Examination

   

NAME:  Mr. John Doe        Pt#:  DO0000                               DATE:  31 Jan 06

 

 

HISTORY:                  Mr. John Doe is a 57 year old male who is seen for his initial Inside Outside “Works” evaluation. His main desire is to lower his risk for Coronary Artery Disease and improve his energy level, lose more body fat and increase his muscle mass. 

 

SOCIAL HISTORY:   Mr. Doe is fully employed as the CEO of Widgets, Inc, a company which manufactures high end widgets.  He travels frequently in his job. He is married has one son, age 30 in good health.   He does not admit to any marital distress.  Upon questioning he admits only to the usual job stresses associated with his business but he relates no financial stress.  He feels some loss of mental functioning and energy associated with the aging process.  He has never smoked. He takes alcohol rarely as it makes him feel bad. 

 

FAMILY HISTORY:    He has one sibling, an older sister who has migraines. His Mother is alive and in fair health at age 84.  His Father died at age 74 of Lung Carcinoma.  His father also had adult onset diabetes.

 

ROS:                           At the present time he has no Cardiac symptoms and reports normal cardiac treadmill testing in 1995.  There are no respiratory symptoms. He had abdominal pain and was diagnosed with Diverticulitis and required sigmoidectomy in 2001.  At this time there are no GI complaints.  He has had several episodes of prostatitis associated with slightly elevated PSA levels and he is followed by Dr. Richard Doe for this. There are no GU symptoms at this time other than nocturia x 1. He has spasm in his right neck quite frequently thought related to muscular tension and a nagging pain in the left groin related to activity at times. There are no neurological symptoms other than a mild sense of loss of concentration, rapid mood swings, impatience, and lack of mental alertness.  He frequently has late afternoon drowsiness but this is helped by taking Excedrin Plus with caffeine in the early afternoon.

 

PAST MEDICAL HX: He has had a remote appendectomy, tonsillectomy and open reduction/fixation of a left clavicular fracture.  In 2001 he underwent sigmoidectomy for

Diverticulitis. He takes Lipitor 20mg for his lipids and intermittently takes DHEA 20mg which makes him feel better.

   

 

DIETARY HISTORY: He appear to have reasonable eating habits but has been inconsistent. He rarely uses alcohol and drinks tea several times daily.  

 

 

EXERCISE HX:          He has belonged to a gym for over 20 years and has a treadmill and free weights at his home. He works out 4-5 times a week and does mostly aerobic and a little bit of resistance training and stretching. 

 

ALLERGIES:              None.

 PHYSICAL EXAM:     General: Middle aged Caucasian male, no distress. 

Vital Signs: Ht 5’10”, Wt 190.6, BP 122/78, Pulse 84 and Regular.

HEENT:  Ears clear, TM Bright, Pupils reactive. Oral Exam shows good hygiene and repair, no suspicious lesions.  Neck with no masses and there are no carotid bruits. No obvious cranial nerve defects.

Chest: There are good breath sounds bilaterally. There is a scar and deformity over the left clavicle.

Cardiac: There is a regular rhythm without murmurs.

Abdominal:  Liver or spleen not palpable.  Mild central obesity.  No masses or abdominal bruits. Testicles are normal without masses however there is a left variococoel. There are no hernias. There is a well healed midline incision.

Rectal: The prostate is not enlarged and there are no masses

Extremities:  No significant varicosities. Good peripheral pulses however there is a left femoral bruit and several tender lymph nodes in the left groin.

Skin: No suspicious lesions, neck, face, back, fingernails, however he has very fair skin and many sun related photoaging changes.

                                    Neuromuscular: No apparent weakness or abnormalities.

 

MEDICATIONS:         Lipitor 10 mg daily and Occasional DHEA 20 mg daily. He takes a multivitamin daily.

 

DATABASE:               Medical History Form, Cenegenics Quest Lab Data, Inside Outside Lipid, Hormone and Glucose Charts, DXA Scan of Hip, Spine and Forearm, DXA Body Composition, GSDL Cardiovascular Profile, AA/EPA Ratio, Genovations Genomic Testing, Spectracell Antioxidant Status and Zone Prescription.

 

 

     

Charles B. Christian, Jr. M.D.

Medical Director

 

 

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