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PAST MEDICAL HISTORY: The patient has hypertension x10 years.
ALLERGIES: No known drug allergies.
MEDICATIONS: Ambien and Coreg as well as omeprazole 20 mg p.o. dail=
y.
FAMILY HISTORY: Father died of unknown reason (old age). Mother die=
d of
old age. One brother in
SOCIAL HISTORY: The patient was an exsmoker, smoked 8 packs a year =
and
stopped almost 15 years ago. Denied history of drinking=
.
The patient is a retired musician.
REVIEW OF SYSTEMS: General: No weight change, occasional chills, no
sleep disorder. Eyes: Negative, cataracts positive. ENT: Decrease in hearin=
g.
Heart: No chest pain, irregular heart beat. Endocrine: Negative. Psychologi=
cal:
Negative. Blood & Lymphatics: Negative. Urination: Nocturia. Muscle &am=
p;
Bone: Negative. Skin: Negative. Neurological: Negative. Lungs: No
wheezing. No shortness of breath. GI Negative. Allergy: Negative.
PHYSICAL EXAMINATION: Shows an obese female in no apparent distress.
Weight is 311 pounds. Blood pressure is 120/70. HEENT: EOMI (Extraocular muscles are intact), PERRLA, sclera is nonicteric. =
Neck
is supple. Lungs are clear to auscultation and percussion. Cardiac exam sho=
ws
normal sinus rhythm. Abdomen is soft. There is no organomegaly. A right upp=
er
quadrant surgical scar is noted. No peripheral lymphadenopathy. Extremities
show 2+ pitting edema. Neurological is grossly intact. Skin shows no petech=
iae
and ecchymosis. There is no peripheral lymphadenopathy.