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PAST MEDICAL HISTORY: Asthma, status post
hysterectomy, and status post umbilical hernia repair. The patient is status
post multiple colonoscopies for diverticular disease.
FAMILY HISTORY: The patient’s brother died =
of
colon cancer. No family history of gastric cancer, pancreatic cancer,
hepatic cancer, inflammatory bowel disease, or peptic ulcer disease.
REVIEW OF SYSTEMS: No nausea, vomiting, melena,
bright red blood per rectum, weight loss or loss of appetite.
PHYSICAL EXAMINATION:
Vital signs: Blood pressure is 120/70. Pulse is 68
per minute. Respiratory rate is 18.
General: This is a well-developed, well-nourished
female in no acute distress.
HEENT: Normocephalic, atraumatic and anicteric.
Conjunctiva is clear. Extraocular movements are intact.
Neck: No jugular venous distension. No carotid
bruits.
Lungs: Clear to auscultation and percussion.
Heart: Regular rate and rhythm with 3/6 systolic
murmur; no gallops or rubs (the patient was noted to have murmur and has be=
en
instructed regarding antibiotics prior to dental procedures).
Abdomen: Soft and nontender. Bowel sounds are
present. No palpable masses. No hepatosplenomegaly.
Skin: Good turgor.
Extremities: Without clubbing or edema.
Nodes: No cervical or axillary adenopathy is
appreciated.
Neurologic: The patient is alert and oriente=
d to
person, place and time; cranial nerves are grossly intact. No cogwheeling or
resting tremor is noted.