his motorcycle, spending time at the beach with his 5 grandchildren; exercise 5 days a week; eating habits have been “much better since the weight loss surgery”. Immunization History: Agrees to receive his influenza and Pneumococcal today. All other immunizations are up to date. Significant Family History: Diabetes – mother dx late 30s Hypertension - maternal grandparents, mother, brother all dx in late 30s Arthritis – paternal grandfather, father both dx early 40s Psoriasis – father dx date unknown 2 healthy daughters and 2 grandchildren Lifestyle: © 2014 Laureate Education, Inc. Page 2 of 7
He is married to his wife of 32 years. Together they travel the country in their RV and motorcycles. He has owned his home for the past 28 years in the suburbs. At 25 years as a U.S. Marine, he retired and receives full benefits of $75,000 annually. He and his wife both receive social security benefits. No financial issues. First born daughter rents the basement with her 2 children ages 5 and 12. Following his gastric bypass surgery, his health taken a turn for the better by decreasing his meat and increasing his vegetable intake. His total weight loss since the surgery is 143 lbs. He is now only taking one blood pressure medication, down from two. 5 days a week, he exercises at the local YMCA. When he is not traveling the country, he attends church Mondays and Thursdays for Bible study. He also leads the marriage ministry for newlyweds. He has a great support system including his friends and family. Review of Systems: General: Negative for recent sudden weight changes, weakness, fatigue, anorexia, malaise, or fever HEENT: negative for headache, head injury, visual changes, blurring of vision, itching, last eye exam 2/15/18. Negative for diplopia, floaters, loss of any visual fields, history of cataracts or glaucoma, pain, redness, excessive tearing. Negative for tinnitus, recent ear infections, hearing loss, change in hearing. Negative for epistaxis, frequent colds, nasal congestion, discharge, pain, post- nasal drip, change in ability to smell, history of nasal polyps, hay fever, and sinus trouble. Negative for mouth soreness, dryness, bleeding gums, throat soreness, pyorrhea, ulcers, and teeth dentures. Positive for recurrent strep throat infections (3 within 5 months) and dental caries. Neck: negative for painful lymphnodes, enlarged lymphnodes, goiter Breasts: negative for new or changing breast lumps, nipple changes or nipple discharge, gynecomastia Respiratory: negative for cough, hemoptysis, wheezing, shortness of breath, dyspnea, pleuritic chest pain, cyanosis, recurrent pneumonia, environmental exposure, history of exposure to TB, last TB skin test 4/3/17-negative Cardiovascular/Peripheral Vascular: negative for chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, edema, palpitations, murmur, varicosities, history of rheumatic fever, syncope, claudication, thrombophlebitis. Positive for hypertension and history of abnormal electrocardiogram © 2014 Laureate Education, Inc. Page 3 of 7
Gastrointestinal: negative for abdominal pain, nausea, vomiting, hematemesis,
You've reached the end of your free preview.
Want to read all 7 pages?
- Fall '18
- psoriatic arthritis, plaque psoriasis