Allergies 1 No known drug food or environmental allergies ROS General Denies

Allergies 1 no known drug food or environmental

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Allergies: 1. No known drug, food, or environmental allergies. ROS: General: Denies any fever, chills, sweats, or fatigue. Alert and Oriented. Date Client Age Sex Ethnicity ICD Code Pharmacy Intervention(s) Student Level Integumentary: Denies any changes to skin, dry skin, abrasions, bruising, changes to hair or nails. HEENT: Denies any headaches, dizziness, changes in vision, blurry vision, ear pain, hearing difficulties, nasal drainage, changes or difficulty with smell, sore throat, changes in taste, or dental complaints. Lymphatic: denies any swollen or painful lymph nodes. Lungs/chest: Denies any difficulty breathing, shortness of breath, cough, sputum, wheezing. Cardiac: Denies any chest pain, shortness of breath, palpitations, edema, claudication, or ever seeing a cardiologist. Reports family history hypertension, hyperlipidemia, and cardiac stents. Only cardiac testing he has had done was an EKG a year ago during an office visit, and now an elevated BP. Gastrointestinal: Denies any reflux, nausea, vomiting, abdominal pain, diarrhea, constipation, changes in bowel habits, blood in stool, or gall stones. Endocrine: Denies any intolerance to heat or cold, thyroid enlargement, unplanned weight changes, polydipsia, polyuria, polyphagia, changes in face or body hair, changes to skin, or problems with sexual activity. Reports routine self-testicular exams, and does have a family history of hypothyroidism. Genitourinary: Denies any changes in urinary habits, changes in urine flow or color, problems starting or stopping stream, testicular pain, and history of STIs, UTIs, or kidney stones. Musculoskeletal: Denies any pain, stiffness, heat, or swelling of the bones or joints, and denies any muscle pain. Neurological: denies any tingling, numbness, paresthesias, syncope, dizziness, tremors, or seizures. Psychiatric: Denies any history of depression, mood swings, nervousness, suicidal thoughts, or difficulty with concentration. O .
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Vital signs: Temperature: 97.7, heart rate: 42, blood pressure: 156/90, respirations: 18, pain level: “0/10.” General: Well developed Caucasian male, alert, oriented, no acute distress, appropriate affect, pleasant with conversation. Does not appear anxious and appropriate responses to questions. Integumentary: Skin turgor WNL, no abrasions bites or lacerations noted to exposed skin. Skin dry and warm with no noted erythema. Hair is distributed evenly over scalp. Nails appear normal without clubbing, splitting, or pitting. No swelling. HEENT: Head is normocephalic and symmetrical. Pupils round reactive to light. No scleroicteris, moist mucous membranes. No lymphatonopathy, no thyromegaly, bruits, neck supple. Lungs/chest: Chest is symmetrical, respirations are even, non-labored and with ease. Lungs are clear to auscultation and percussion bilaterally. Cardiac/vascular: Normal S1 and S2, regular rate and rhythm, no murmurs, gallops, carotid or abdominal bruits, JVD, clicks, snaps, heaves, or thrills. PMI is palpated at the 5ICS, midclavicular line. 2+ radial, carotid, and dorsalis pedal pulses bilaterally. No noted swelling, varicosities, coolness, or pallor or lower extremities. EKG from last year showed sinus
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