she makes traditional Korean dishes but usually eats very light. patient states she tries to supplement fiber intake by eating at least one vegetablea day. patient states she is currently sexually active with a male partner. Family history includes mother deceased at age 88 history of hypertension and Diabetes Type 2 father deceased at age 82 history of hypertension hypercholesterolemia Maternal grandparents family history of coronary artery disease and Diabetes Type 2 paternal grandparents family history of obesity of water and fluids. Previously shereports regular brown soft stools every day to every other day.
CVA hypertension siblings brother 80 history of hypertension hypercholesterolemia prostate cancer Brother 81 history of HTN. Son and daughter are age 48 and 46 respectively and both are healthy. Review of systems constitutional: positive for fatigue and chills patient denies weight loss and weakness. Heent patient denies visual loss blurred vision double vision yellow sclera no hearing loss sneezing congestion runny nose or sore throat Integumentary positive for intermittent dryness of the skin Patient denies rash or itching Cardiovascular patient denies chest pain, chest pressure or discomfort. No palpitations were edema. Respiratory patient denies shortness of breath, cough or sputum production. Gastrointestinal patient positive for abdominal pain, diarrhea, nausea and anorexia. Patient denies vomiting or bloody stools. Genitourinary patient denies dysuria patient states last menstrual period was 20 years ago. Neurological: patient denies headaches, dizziness, syncope, processes, Ataxia, numbness or tingling in the extremities. No change in bowel or
bladder control. Musculoskeletal patient positive for joint stiffness early in the morning but the subsides over the day patient denies muscle pain or back pain and joint pain. hematological: patient denies anemia, bleeding, or bruising Lymphatics patient denies enlarged lymph nodes no history of splenectomy Psychiatric no history of depression or anxiety Endocrine patient denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia Allergies: positive for latex ObjectiveVital Signs temperature 37° C heart rate 92 respiratory rate of 16blood pressure 110/70 spo2 99% on room air. Skull is symmetrical facial features are symmetrical noabnormalities noted. Nares are moist and pink bilaterally. Oral mucosa is moist and pink Abdomen is flat in symmetrical with scarring noted to the right upper quadrant and above the pubic symphysis Lower extremities are symmetrical with no edema present. S1 S2 and S3
- Fall '15
- Crohn's disease, Bowel obstruction