Current Medications: Tylenol 650mg every 8 hours for 3 days, halls cough drops for 3 days 1 tab every 2 to 3 hours, Multivitamin 1 tab daily
Allergies: NKA
PMHx: Current on immunizations, had flu shot October 2017, las
...
Current Medications: Tylenol 650mg every 8 hours for 3 days, halls cough drops for 3 days 1 tab every 2 to 3 hours, Multivitamin 1 tab daily
Allergies: NKA
PMHx: Current on immunizations, had flu shot October 2017, last tetanus was last May 2017. No pertinent medical history reported. No hospitalizations reported. Denies any history of accidents/injury or falls.
Soc Hx: Ms. L was born in Liberal, KS and currently attends a Seward County Community College, she is studying for cosmetology. Drives to school and work and states she always wears her seatbelt. She is a full-time student and works part time at a restaurant. She is in a relationship, and heterosexual, and sexually active. Has no children and never been pregnant.
She exercises 3x/week, and eats a high protein and low carb diet. She is a social drinker, takes 1- 2 beers occasionally about every other month. Never smoked, and denies use of illicit/recreational drugs. Has a good support system her parents and one sister.
Fam Hx:
Mother: age 59, HTN and Pancreatitis Father: age 61, HTN and DM type 2 Siblings: 1 older sister and no health issues
Maternal Grandmother: deceased at age 83 due to MI Maternal Grandfather: deceased at age 79 due to CVA Paternal Grandmother: age 86, living HTN, DM, hx of CVA Paternal Grandfather: deceased at age 60 due to MI
ROS:
GENERAL: Patient is Alert and Orientated X 3, appears tired, no weight loss, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. No decreased hearing. No hearing loss, sneezing, or congestion. Has complaints of runny nose, sore throat, headaches, and hoarse voice.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath or cough
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Complaints of decreased appetite
GENITOURINARY: Denies burning in urination, never been pregnant. Menses are regular, last menstrual period, 03/20/2018
NEUROLOGICAL: No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. Complains of headache that started with the onset of sore throat 3 days ago
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding
...................................................................CONTINUED..................................................................
[Show More]
.png)
