History and Physical Examination

Patient Name: Luedy, Jordan

DOB: August 25, 1995
Gender: Female
Ethnicity: Caucasian
Data Source: Patient

Chief Complaint: No chief complaint. Presenting to the clinic today for annual physical
examination.

History & Present Illness: Jordan Luedy, a 26-year-old female who was verified by name and
DOB presented to clinic today as a new patient for her annual physical examination. Patient is in
good health.

Allergy:
Tuberculin; patient is a reactor to TB test
Seasonal/Environmental

Physical Examination:

Vital signs:
Temperature: 98.2F
Respiratory Rate: 20breaths/min
Blood pressure: 117/86
Heart Rate: 84bpm
Pulse ox: 100% RA
Pain score: 0/10

General: Patient is alert and oriented to person, place, and time. Well developed, hydrated, and
nourished. Seem comfortable, relaxed, and not in distressed.

Psychiatric: Appropriate mood and affect. Good judgement and insight. No visual or auditory
hallucinations. No suicidal or homicidal ideations. Denies anxiety, depression, or sleep
disturbances.

Skin: Hair is of normal texture and evenly distributed. Skin is warm, dry, and intact and without
erythema, rash, or excessive dryness. No excessive sweating. Elastic skin turgor noted. No
discoloration of skin noted. No cyanosis or clubbing of the nails noted. Capillary refill is less
than three seconds. No tenderness with palpation. Patient have many tattoos throughout entire
body.

HEENT: No head injuries noted. The head is normocephalic and atraumatic without tenderness.
No visible masses, depressions, or scarring from the scalp. Hair on scalp is normal texture and
evenly distributed. No dandruff, parasites, or lesions noted. Face is symmetrical, normal color,
no twitching, or involuntary movements noted. Ears are free from cerumen, lesions, foreign
bodies, and obstruction. Tympanic membrane is gray in color and shiny. No drainage, redness or
inflammation noted in ear canal. Passed Weber, Rinne, and Whisper Tests. Eyes PERRLA.
Pupils are 3 bilaterally. Orbits, eyelids, conjunctivae, and sclera are normal. Vision grossly
intact. Funduscopic examination is unremarkable. Brows, lids, and lashes intact. Nasal mucosa
pink and moist. No septum deviation present. No drainage and tenderness to the nares. Throat is
pink and moist, smooth, and consistent in texture. Uvula pink and rounded. No signs of sores or
lesions within mouth, throat, buccal lining, tongue, and gingiva. Oral mucosa is pink with good
dentition. No dryness, lesions, sores noted to lips. No cavities or missing teeth present. Positive
gag reflex.

Neck: Easily moveable. No masses, webbing, and excessive skinfolds noted. Trachea midline.
Thyroid gland is not enlarged and without any palpable masses. Carotid pulse is 2+ bilaterally.
No JVD.

Respiratory: Upon inspection, the chest wall is symmetric and without deformity. No
abnormality with chest diameter. No signs of trauma. Chest wall is non-tender. Patient is sitting
in an upright position, comfortable, with no signs of respiratory distress. Chest movement
symmetrical with no usage of accessory muscles. No pursed lips, cyanosis, or prolonged
respiratory phase noted. Respiratory rate 20/minute and is not tachypneic. Thoracic expansion
equal bilaterally and tactile fremitus is normal throughout. No adventitious breath sounds noted.
Resonance noted with percussion to all lung fields.

Cardiac: The external chest is normal in appearance without heaves, lifts, or thrills. No chest
pain noted. Precordium without visible pulsations. PMI is palpated in the 5th intercostal space at
the midclavicular line. Apical pulse is 84. Heart rate and rhythm are normal. S1, S2 noted
without murmurs and are of normal intensity. No S3 and S4 present when auscultating.

Vascular: Upon inspection, no signs of peripheral veins and arteries insufficiencies noted.
Pulses to carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibia are all 2+
bilaterally. No edema noted in all four extremities. Skin is warm and dry. Capillary refill <2
seconds. JVD not present. No bruits present when auscultating the carotid, abdominal aorta,
renal, iliac, and femoral arteries.

Breasts: No dimpling or abnormalities noted upon inspection. Nipples symmetrical. Denies

tenderness or pain to bilateral breasts. No skin changes, nipple discharge, masses, and lesions
noted. Lymphadenopathy not present to bilateral axillary region.

Gastrointestinal: Upon inspection abdomen color is appropriate for race. No jaundice, cyanosis,
scars, lesions, distention or mass noted. Patient has several tattoos noted on abdomen. Active
bowel sounds in all four quadrants. No abdominal aorta, renal, iliac, or femoral bruits present
when auscultated. Abdomen is flat, soft, and nontender with palpation and percussion. Umbilicus
is midline without herniation. Tympany to percussion in three of the four quadrants. Dullness to
LUQ noted with percussing. Liver span is 6.604cm (2.6in.). Liver, gallbladder, and spleen
nonpalpable. No masses, hepatomegaly, or splenomegaly are noted. Pulsation present from
abdominal aorta. No kidney tenderness when direct percussing of the costovertebral angle.

Genital/Rectal: Normal rectal sphincter tone. No masses, lesions, and tenderness present. Stool
is soft and brown. Stool guaiac test negative. Normal external genitalia upon inspection.
Speculum examination shows normal vagina and cervix. Uterus, ovaries and mases absent when
palpating.

Musculoskeletal: Upper and lower extremities are atraumatic in appearance without tenderness
or deformity. No swelling, warmth, tenderness, and crepitus when palpating all bones, joints, and
surrounding muscles. Full range of motion is noted to all joints. Muscle strength is 5/5
bilaterally. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities.
Pulses palpable. Steady gait noted.

Neurological: Awake, alert, and oriented to person, place, and time with normal speech. Motor
function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Romberg
test negative. Sensory function is intact bilaterally. Reflexes 2+ bilaterally. Cranial nerves I-XII
are intact. Cerebellar function is intact. Memory (immediate, recent, and remote) normal and
thought process is intact. No gait abnormalities are appreciated. Superficial and deep tendon
reflexes intact. Babinski test negative.

Mental Status Exam: (not included in video)

Patient is A&O x3. Patient able to answer the correct date, location, and date of birth. Patient
successfully differentiate between simple objects such as peach vs lemon and flute vs trumpet.
When asked about the metaphor “Life is a highway,” patient able to use abstract reasoning to
explain the meaning of the metaphor. Arithmetic calculations done correctly. No impairment to
writing ability and motor skills. Patient was able to write her full name and address without
difficulty. When asked to brush her hair and tie it into a ponytail, she performed it with ease.
Patient successfully repeated the five numbers “1, 4, 10, 17, and 32” back using immediate
memory. Recent and remote memory were correct. Patient repeated all four objects shown to her
at the beginning of the interview correctly. Patient able to report the correct answer to the
question of “If you were to find money on the ground, what would be the correct thing to do with
it?” Patient able to answer to all various questions with no aphasia, slurring, stuttering,
forgetfulness.