HISTORY AND PHYSICAL EXAMINATION
Patient Name: John Marcelino
CHIEF COMPLAINT
The Patient wants to begin regular physical examinations as part of routine healthcare.
HISTORY OF PRESENT ILLNESS
Medications: No current medications except for daily multivitamins.
Illnesses: Usual childhood diseases (measles, mumps, chickenpox). He had no serious
illnesses.
Operations: Appendectomy, no complications and the like.
PAST HISTORY
There is a history of rash with oral medication.
Social History: Smokes a half a pack of cigarettes per day, denies alcohol or recreational drug
use. Married husband, volunteer time at the humane society caring for sick animals.
Family History: Father, mother and one brother living and well. Maternal grandfather dies at
age 55 from complications of diabetes. No other family history of heart or thyroid disease or
cancer.
ALLERGIES
Allergic to penicillin.
REVIEW OF SYSTEM
Skin: Dry and cool to touch without discoloration for the skin. Well healed appendectomy scar in
the abdomen.
Hair: Normal distribution and texture of the hair.
Cardiorespiratory: No history of murmurs and chest pain. Mild nonproductive cough with
smoking.
Gastrointestinal: Good appetite, no significant change in weight for 5 years. Stools formed and
normal in color, denies vomiting or blood in stool.
Gynecologic: Spontaneous abortion, 6 weeks for his wife.
PHYSICAL EXAMINATION
General: The patient is well-nourished, well-developed, white male in no acute distress who
appears slightly older than his stated age of 42. That is the general examination given by his
other doctor. The patient is oriented to time, place and person.
Vital Signs: Pulse: 88 per minute. Blood Pressure: 120/77. Respiratory Rate: 98.6°F.
Chest: Thyroid moves with swallowing and is not enlarged, no masses, no bruits. Heart rates or
heart tones are normal. Lungs, clear and percussions. Breast, symmetrical without masses or
distortion.
Abdomen: Soft bowel sounds are normal, no pain or rebound tenderness at palpation.
Pelvic: The external genitalia are normal. Pelvic examination was deferred.
Rectal: No hemorrhoids or masses, no blood in stool or in the examining finger.
Neurologic: Cranial nerves, 2 to 12 are grossly intact. Deep tendon reflexes are equal
bilaterally.
ASSESSMENT
Normal physical examination and pelvic examination deferred.
RECOMMENDATION/PLAN
Refer to Gynecologist for pelvic examination, chest X-ray, routine blood work, urinalysis. Patient
to call when tests and referral are completed. To schedule return visit for results and to discuss
methods to control or quit smoking. In the absence of abnormal results, the patient is advised to
return in one year for routine examination.
Jess Dela Cerna, MD
December 18, 2018
CHART NOTE
Patient Name: Eugene Dela Cruz
Subjective: The mother brought in this 1-month-old male. The patient is doing very well. They
have been using the phototherapy blanket.
Objective: He is thirsty, has good yellow stooling, and continues on formula. His alertness is
normal. Other pertinent review of system is non-contributory.
Assessment: Afebrile, comfortable. Jaundice is only minimal at this time. No scleral icterus,
good activity level, normal fontanel. TMs’, nose, mouth, pharynx, neck, heart, lungs, abdomen,
liver, spleen, and jaw and groins are normal. Normal cord care and circumcision, good
extremities. As revolving physiologic jaundice on phototherapy.
Plan: We’ll stop phototherapy in a couple of days to make sure there’s no rebound. The patient
is to be seen in 1 week. Routine care was discussed.
Deborah Lippmann, MD
May 30, 2020
