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annual physicals. EKG performed three months ago with no abnormal findings. See Dr. Smith every six months. Patient reports he does not have a cardiologist. Family History: Father had HTN, HLD and obesity and died at 75 from colon CA. Mother- 80 yo with type 2 DM and HTN. Brother- passed at 24 yo from MVA. Sister- 52 yo with type 2
DM, HTN. Maternal Grandmother- died of breast CA, age 65. Maternal Grandfather- died of MI age 54. Paternal Grandmother- died of pneumonia at 78. Daughter- Asthma, age 19.Social history: Denies tobacco or drug use. Drinks 2-3 beers a week. ROS:HEENT:Denies changes to vision, hearing or smell. Denies difficulty chewing or swallowing. Skin:Denies rashes, dry skin, itchiness or lesions.Cardio:Denies current chest pain, discomfort or palpitations. Resp:Denies dyspnea and cough. GI:Denies nausea, vomiting or diarrhea. Denies changes in bowel habits. Denies bloating. `Denies ever having GERD. GU:Denies dysuria and hematuria.Neuro:Denies dizziness or syncope. Musck:Denies joint pain or back pain. Heme:Patient denies bruising or bleeding. Lymp:Denies history of CAPsyc:Denies depression or anxiety. Denies any psychiatric disorders.Endo:Denies hormone therapy or temperature intolerances. Allergies:CodeineObjectiveVitals: BP 146/90, 02 sat 98% RA, HR 104, RR 19, Temp 36.7 CGeneral Assessment:Brain Foster is a 58 year old Caucasian male. No acute distress noted. Patient is A&O times fourand appearance, hygiene, eye contact, mood, interactions and behavior were all appropriate.
HEENT:Head- Normocephalic, symmetric facial features, atraumatic. No tenderness noted.