hypercholesterolemia, CVA, neuropathy, subdural hematoma from a fall 2016
Past Surgical History (PSH): Hysterectomy (20 years ago), cholecystectomy (15 years
ago), cervical fusion (2016).
Personal/Social History: Patient denies tobacco, alcohol, or drug use. She is a retired RN.
Immunization History: Patient says she is up to date on her vaccinations and that she did
receive a flu shot this year because it is required by the SNF she lives in
Significant Family History: Include history of parents, grandparents, siblings, and
children. Lifestyle: The patient lives in a skilled nursing facility and is wheelchair
bound due to “weakness”. Her husband lives in the same facility and “used to drink
too much.”
Review of Systems:
General: Patients is sitting in a wheelchair with her head down on a windowsill. She is
dressed appropriately and appears well nourished. She denies any recent fever, chills,
nausea, or weight loss. She says that she has felt weak and fatigued but this is not a new
symptom and it is caused by her depression.
HEENT: The patient denies any headache, dizziness, or neck stiffness. She denies any
swelling, tenderness, or masses. The patient denies any visual changes, or redness, swelling,
drainage, or pain in the eyes. The patient denies any hearing loss, pain, discharge, vertigo,
or tinnitus. The patient denies any epistaxis, itching, or rhinorrhea. She denies bleeding
gums, or mouth sores.
She has a full set of dentures that she says are well fitting. The patient denies a sore throat,
hoarseness, or change in taste.
Breasts: Patient denies any pain, lumps, or discharge.
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