Download History and Physical : Richard Mendoza MR # 8836595 Chief

History and Physical : Richard Mendoza MR # 8836595
Chief Informant: Patient
Chief Complaint: Shortness of breath, fatigue, loss of appetite and weight loss over the past couple of months.
History of Current Problem: Ricardo Mendoza is a 60-year-old Hispanic male. He was seen in the office a few weeks ago
with shortness of breath, increasing fatigue, loss of appetite, and a 15-pound weight loss over the past few months.
Chest X-ray revealed a nodule in the right upper lobe. CT-guided needle biopsy was performed. A diagnosis of squamous
cell lung cancer of the right lung was made, and he was scheduled for lobectomy this AM.
Allergies: No known allergies
Height: 5’6
Weight: 138
Family History: His mother died of alcohol related complications and he has not had contact with his father since
childhood.
Past Medical History
Previous Illnesses: None
Contagious Diseases: No recent known exposure to contagious diseases.
Injuries or Trauma: No significant illnesses or trauma.
Surgical History: Left inguinal hernia repair age 48
Dietary History: Loss of appetite over past few months
Social History: He has a 53-pack-year history of smoking. He reports drinking 4 to 6 beers daily. He is married with 3
sons and works in construction, mainly masonry work.
Current Medications: None
Review of Systems
Integument: Skin intact.
HEENT: Wears glasses for reading.
Cardiovascular: No history of hypertension; no cyanosis or palpitations reported.
Respiratory: Shortness of breath with exertion.
Gastrointestinal: No complaints of indigestion, heartburn, nausea or vomiting. No recent change in bowel movements.
Genitourinary: No history of frequency, dysuria, urgency; no history of urinary tract infections.
Musculoskeletal: Arthritis in hands and knees.
Neurologic: No history of seizures, dizziness, confusion, stroke, or blackouts. No numbness, tingling, or paralysis.
Memory intact.
Endocrine: No history of diabetes; no temperature regulation issues.
Genitalia: No discharge. No complaints.
Lymphatic: No lymphadenopathy.
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