CC
Jamie is a 22-year-old female here today to establish care. She is complaining of some decreased hearing in her left ear.
HPI
The patient tells me her symptoms just recently started. She said she noticed there was perhaps some wax at the edge of her ear. She says she never uses Q-tips, but it was her parents house and tried to get the wax out using a Q-tip and she is afraid she makes the symptoms worse. Following that, she felt she was unable to hear out of her left ear. There has been no pain, however. She has previously not had an issue with her hearing out of that ear. She reports that for a while, one day over the weekend, she felt she could hear better, but then after she awoke the next morning, it was also blocked again. She …show more content…
She uses Sprintec. She had been seeing a gynecologist in Massachusetts, but now is either looking for her gynecology up in Maine, where she is living or would like to do her care here. She has had no problems with the birth control pill. No side effects to it at all and is pleased with the pill that she is on. She would like to get a three month supply, if possible. She is just about due for her physical, pelvic and Pap smear and would be willing to get those records for …show more content…
Father with hypertension, hyperlipidemia, diabetes, alcohol overuse, and tobacco use. She has a sister who is healthy. She is the oldest of the two in her family. Her health history questionnaire is reviewed with her here in the office.
O
Vital Signs
Temperature: 97.9. BP: 118/70. HR: 72. R: 14. H: 5 '5.25". W: 107. BMI: 26.
General
A well-developed, well-nourished female, in no acute distress, seated comfortably in the exam room. She is alert and oriented. Very pleasant. She has good eye contact. Answers questions appropriately. Alert and oriented.
HEENT
Conjunctivae are without erythema. No scleral icterus. No drainage or discharge from the eyes. The right TM appears normal. No erythema or bulging with minimal wax. The left TM is not visible. There is cerumen impaction. The canal that is visible does appear normal. There is no pain with movement of the external ear. Mucous membranes are moist. No mucosal lesions. No exudate. No drainage.
Neck
Supple. No lymphadenopathy.
Heart
Regular rate and rhythm.
Lungs
Clear bilaterally with good breath sounds.
Extremities
No lower extremity
Jamie is a 22-year-old female here today to establish care. She is complaining of some decreased hearing in her left ear.
HPI
The patient tells me her symptoms just recently started. She said she noticed there was perhaps some wax at the edge of her ear. She says she never uses Q-tips, but it was her parents house and tried to get the wax out using a Q-tip and she is afraid she makes the symptoms worse. Following that, she felt she was unable to hear out of her left ear. There has been no pain, however. She has previously not had an issue with her hearing out of that ear. She reports that for a while, one day over the weekend, she felt she could hear better, but then after she awoke the next morning, it was also blocked again. She …show more content…
She uses Sprintec. She had been seeing a gynecologist in Massachusetts, but now is either looking for her gynecology up in Maine, where she is living or would like to do her care here. She has had no problems with the birth control pill. No side effects to it at all and is pleased with the pill that she is on. She would like to get a three month supply, if possible. She is just about due for her physical, pelvic and Pap smear and would be willing to get those records for …show more content…
Father with hypertension, hyperlipidemia, diabetes, alcohol overuse, and tobacco use. She has a sister who is healthy. She is the oldest of the two in her family. Her health history questionnaire is reviewed with her here in the office.
O
Vital Signs
Temperature: 97.9. BP: 118/70. HR: 72. R: 14. H: 5 '5.25". W: 107. BMI: 26.
General
A well-developed, well-nourished female, in no acute distress, seated comfortably in the exam room. She is alert and oriented. Very pleasant. She has good eye contact. Answers questions appropriately. Alert and oriented.
HEENT
Conjunctivae are without erythema. No scleral icterus. No drainage or discharge from the eyes. The right TM appears normal. No erythema or bulging with minimal wax. The left TM is not visible. There is cerumen impaction. The canal that is visible does appear normal. There is no pain with movement of the external ear. Mucous membranes are moist. No mucosal lesions. No exudate. No drainage.
Neck
Supple. No lymphadenopathy.
Heart
Regular rate and rhythm.
Lungs
Clear bilaterally with good breath sounds.
Extremities
No lower extremity