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PAST MEDICAL HISTORY: Cholecystectomy in 1973. The patient had diab=
etes
mellitus 10 years ago, cholesterol for 4 years, bacterial infection and
kidney stones in April 2005.
ALLERGIES: No known drug allergies.
MEDICATIONS: Lipitor 40 mg daily, Toprol XL 50 mg, Actos 15 mg, and
metformin 1000 mg.
FAMILY HISTORY: Father was killed. Mother alive with diabetes and h=
ypertensive
disease. There is no brother. Two sisters, one with diabetes mellitus.
SOCIAL HISTORY: The patient denied history of smoking or drinking. =
The
patient works as a caseworker with no exposure to chemicals or asbestos.
REVIEW OF SYSTEMS: General: The patient has occasional chills. Eyes:
Negative. ENT: Has sinus problem. Heart: Occasional swelling at ankles.
Endocrine: Feels occasional heat intolerance. Psychological: Negative. Blood
& Lymphatics: Anemia with easy bruisibility. Urination: Frequency and
nocturia. Muscle & Bone: Positive for joint pain. Skin: Moist and
intact. Neurological: Occasional numbness and tingling. Lungs: Occasional
wheezing and shortness of breath. GI: Vague epigastric pain. Allergy: Negat=
ive.
PHYSICAL EXAMINATION: Physical examination shows a well-developed,
elderly female in no apparent distress. Weight is 107 pounds. Blood pressur=
e is
140/70. Heart rate is 72, respirations 24. HEENT: EOMI, PERRLA, sclera is
nonicteric. Neck is supple. Lungs are clear to auscultation and percussion.
Cardiac exam shows normal sinus rhythm. Exam of the chest shows irregular m=
ass
and the tumor has shrunk to less than 1 cm in diameter. No axillary lymph n=
ode
is palpable. Abdomen is soft with no organomegaly. Bowel sounds are active.
Extremities show no cyanosis, clubbing or edema. Neurological is grossly
intact. Skin shows no petechiae or ecchymosis.