Past Medical History
Hypertension- Stage II, diagnosed 1 year ago
Hyperlipidemia- diagnosed 1 year ago
Past Surgical History
No surgical history
Family History:
Mom- living diabetes
Sister- living diabetes
Social 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/P
Sexually active with wife of 27 years.
Immunizations:
Tdap 10/2014, Influenza- current for this season
Medications:
Metoprolol 100mg PO Daily
Atorvastatin 20mg PO daily at bedtime
Omega-3 Fish Oil 1200mg PO BID
Allergies Medications/environmental/food ect
Codeine- nausea and vomiting
Denies any food, latex, or environmental allergies
ROS (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.
