Soc Hx: Accountant and competitive dart thrower. Single, heterosexual, denies current sexual partner, states he has no interest in “dating” at this time. Denies smoking, exposed to second hand smoke at Dart competitions.
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Soc Hx: Accountant and competitive dart thrower. Single, heterosexual, denies current sexual partner, states he has no interest in “dating” at this time. Denies smoking, exposed to second hand smoke at Dart competitions. Denies alcohol intake. Reports seat belt use while driving, denies guns in home, lives alone. Reports several caffeinated beverages daily, > 3 cups coffee and soda.
Fam Hx: Father living age 81, coronary artery disease, HTN, and skin cancer unknown type, Mother diseased age 71 breast cancer, Grandparents all diseased unknown health history, One sibling, living, brother age 55, CVA.
ROS:
GENERAL: Denies recent illness, weight loss or gain, denies any fevers, chills, or night sweats.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae, states that eyes are very sensitive to light during headaches. Ears: denies pain, discharge, or hearing changes. Nose: reports seasonal rhinorrhea, reports pain during headaches in sinus area, Throat: Denies pain, denies difficulty speaking or swallowing.
SKIN: Denies any open wounds, sores, lesions, rash, or bruising.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations and edema.
RESPIRATORY: Denies shortness of breath, cough.
GASTROINTESTINAL: Reports anorexia with headaches, nausea, and vomiting.
GENITOURINARY: Denies burning on urination, increased frequency, or nocturea.
NEUROLOGICAL: Intermittent headaches, denies dizziness, denies syncope, denies paralysis, ataxia, numbness or tingling in the extremities. Denies changes in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies bleeding of gums, denies frequent bruising.
LYMPHATICS: Denies enlarged nodes.
PSYCHIATRIC: Reports history of depression and anxiety, has never sought treatment. Reports good mood recently.
ENDOCRINOLOGIC: Denies excessive thirst, hunger, or need to urinate.
ALLERGIES: Seasonal allergies with Rhinorrhea and sneezing, treated with nasal spray. Strawberries and Latex produce rash response.
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