Pre-Employment Exam

The patient is a 35-year-old male, sir. He has no known drug allergies. Code status is full code. He is a non-smoker. He is fully independent in all activities of daily living. His occupation is a construction worker. He is right-hand dominant. He is accompanied by his wife. Past Medical History: 1. History of controlled hypertension diagnosed 5 years ago, managed with medication. No recent investigations. Treatment with Amlodipine 5mg daily. - Social history: Occasional alcohol consumption (2-3 units per week), denies illicit drug use. Lives with wife and two children. Stresses related to work demands. - Family history: Father had hypertension and type 2 diabetes. Mother is healthy. - Exposure history: Exposed to dust and loud noises in his construction work environment. Uses appropriate PPE as required by employer. - Other: Reports occasional lower back stiffness, managed with over-the-counter pain relievers. Vaccination History: - Up-to-date with routine adult immunizations, including tetanus booster 2 years ago. Received COVID-19 primary series and one booster. Family History: - Father with hypertension and type 2 diabetes. Mother healthy. Paternal uncle had a myocardial infarction at age 60. Presenting: 1) Pre-employment medical examination - Reason for visit: Required medical examination for a new position as a construction site foreman. - Duration: This is a routine check-up, no acute complaints. - Impact on daily activities: No current symptoms affecting daily life or work. - Associated symptoms: Denies any acute symptoms; feeling well overall. Examination: Afebrile Vitals unremarkable GCS 15 PEARL. EOM full No subconjunctival pallor No scleral icterus Ophthalmoscopy: Normal bilaterally. No papilloedema Otoscopy: TM clear bilaterally Mucous membranes moist CN II-XII grossly intact No focal upper limb or lower limb neuro deficits No cerebellar signs Steady gait No spinal tenderness or step deformity H S1S2. No murmur L Clear A Soft. Non-tender Murphy's negative No hepatosplenomegaly BS+ Hernia orifices clear Calves supple No pedal oedema No rash Impression: 1) Pre-employment medical examination Plan: - Investigations planned: Routine blood work (FBC, U&E, LFTs, Glucose), urinalysis, chest X-ray, audiometry, and spirometry per company protocol. - Treatment planned: Continue current hypertension medication. Advised on maintaining a healthy lifestyle. - Relevant other actions: Complete employer-provided medical fitness forms. Follow-up for results and final clearance.