100%(4)4 out of 4 people found this document helpful
This preview shows page 1 - 3 out of 3 pages.
Past Medical HistoryHypertension- Stage II, diagnosed 1 year agoHyperlipidemia- diagnosed 1 year agoPast Surgical HistoryNo surgical historyFamily History: Mom- living diabetesSister- living diabetesSocial History:Denies any tobacco use, denies any illicit substance abuse, denies salting his food. Reports he does drink 1-2 beers or a whiskey once in awhile while grilling on the weekends or being social with friends. Denies alcohol has ever been a problem for him. Sexual/Reproductive History: as applicable, always include LMP and G/PSexually active with wife of 27 years.Immunizations:Tdap 10/2014, Influenza- current for this seasonMedications:Metoprolol 100mg PO DailyAtorvastatin 20mg PO daily at bedtime
Omega-3 Fish Oil 1200mg PO BID Allergies Medications/environmental/food ectCodeine- nausea and vomitingDenies any food, latex, or environmental allergiesROS (this will also be as it r/t to the case/patient)Constitutional: Alert and oriented, clear speech, does not appear to be in distress Respiratory: even, unlabored, LCTA in anterior bilateral upper and lower lobes, and posteriorly in bilateral upper lobes. Bilateral lower lobes posteriorly with fine crackles.