RUA Health History and Physical exam (2)

Subjective Data AB is 5 feet 11 inches 240 lb 25 year old, single, male presenting today for his annual exam with no specific health complaints. Patient states “I feel overall healthy. I try and stay active as much as I can and eat healthy.” Patient states “As a child I had chicken pox.” Patient also states “In College I broke my right wrist during a football game and had to have surgery. I now have a metal plate with three screws in my right wrist.” Patient has no known drug allergies and currently takes OTC Prilosec. Patient states “I also do have a sensitivity to gluten and dairy. I am working on cutting it out of my diet, but will accidently have it every once in a while and I feel sick with diarrhea, brain fog, and drowsiness.” Patient is AOx 3 and is answering my questions appropriately. Patient family history includes: Mother: 56, Alive with high blood pressure with current medication treatment Father: 57, Alive with high cholesterol and high blood perssure with medication treatment Maternal Grandmother: Deceased (unknown cause) Maternal Grandfather: Alive, 85 years old with Type 2 Diabetes. Paternal Grandmother: Deceased at age 75 from Cancer (type unknown.) Paternal Grandfather: Alive, 82 years old with CPOD treated with Oxygen. Sister: Alive, 27 years old with no known health issues. Brother: Alive, 20 years old with ADHD treated with Adderall prescription. Skin: Skin appears appropriate color for ethnicity with pink undertones. Patient states “When I was in middle school I had eczema that I treated with cream.” Pt denies any current skin issues or disorders. Hair: Hair appears coarse and appropriate for ethnicity. Nails: Nails appear appropriate in color with pink undertones. Patient denies and breaking or brittleness of nails. Head: Patient states “I played College Football for four years and in the NFL for two years and have been hit in the head many times with a few concussions.” Pt denies headaches, dizziness, and vertigo. Eyes: Patient denies eye pain, redness, and vision changes. Pt states “I wear contact lenses every day and visit my eye doctor every year.” Ears: Patient denies ear pain, hearing loss, and vertigo. Nose and Sinuses: Patient denies sinus pain, nose discharge, nosebleeds, and colds within the last year. Mouth and Throat: Patient denies sore throat, sores in mouth or throat, and voice changes. Patient states “I practice good mouth hygiene and go to my dentist every 6-12 months.” Breast: Patient denies pain, lumps, and rash in breast area. Respiratory System: Patient denies history of any lung/respiratory disease. Patient states “I have been told I snore from time to time.” Cardiovascular System: Patient denies chest pain, tightness, and palpitations. Patient .....................................CONTINUED..............................