A 56-year-old Established patient presents to his family physician for a preventive check up at the local outpatient clinic. The physician conduct a multi system history and physical examination, and the check up takes 45 minutes
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Answer:
History:
The patient reported that he is in overall good health and has been feeling well since his last check up. He reported no new medical problems, no changes in diet or exercise, and no new medications.
Physical Exam:
The physician began the physical exam by measuring the patient's weight, height, and blood pressure. He then conducted a full physical exam, inspecting the patient's skin, eyes, ears, nose, throat, and mouth. In addition, the physician conducted a neurological examination, checking the patient's reflexes, muscle strength, and sensation. The physician also listened to the patient's heart and lungs, and performed a digital rectal exam. The physician discussed the results of the physical exam with the patient and answered any questions he had. The physician also offered lifestyle advice and discussed any recommended screenings or test.
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