Sister has a history of lupus. Lifestyle : Patient is a married male, and father of 3 currently working as a manager at a local restaurant (60-70hours a week) ; high school graduate; current income is 30,000 annually ; resides in the city in a high crime area. His wife is a stay at home mother, so he admits to additional stress related to finances. Mr. Cook’s religion is nondenominational, and he admits he can only attend church once a month, due to having to work overtime. Mr. Cook is currently compliant with his routine provider visits and takes prescribed medication as ordered: he has health insurance at this time. He admits to having supportive family and friends, however, doesn’t spend a lot of time with them, due to his long hours at work. Review of Systems: General: Recent weight loss of 10lbs in the past month. Joint pain bilateral. He denies symptoms of weakness, fatigue, or fever, HEENT: No visual or hearing complaints or changes, last eye exam two years ago, does not wear eyeglasses or contacts. Patient denies infections, visual disturbance, trauma, or abnormal conditions to eye bilat. Patient denies infections, pain, tinnitus, injury, or any unusual problems to ear bilat. Patient’s sense of smell is intact. No infections or polyps to nasal cavity and patient denies allergic rhinitis, postnasal drainage or nosebleeds. Last dental cleaning and exam 05/2016. Mr. Cook denies any history of dental infection, ulcers, gingivitis, toothaches or foreign dental equipment; He has no complications related to chewing or swallowing food or fluids. Neck: No pain, tenderness, swelling, discoloration, or injury noted. Breasts: Denies current and past abnormal findings in breast bilat. Breast is free of mass, lesions or rashes. Respiratory: Denies current and past respiratory distress/complication; Last PPD 05/2016 (0mm). No shortness of breath or dyspnea. Cardiovascular/Peripheral Vascular: Denies chest-pain or heart palpations currently or in the past. Denies any other pain or discomfort in the chest. He admits to a diagnosis of hypertension 5/2016. Last ECG completed in 2017.
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- Summer '16
- Medical diagnosis, Differential diagnosis