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Father died at age 43 in train accident. Mother died at age 67 of stroke; had varicose veins, headaches One brother, 61, with hypertension, otherwise well; one brother, 58, well except for mild arthritis; one sister, died in infancy of unknown cause Husband died at age 54 of heart attack

Daughter, 33, with migraine headaches, otherwise well; son, 31, with headaches; son, 27, well

No family history of diabetes, tuberculosis, heart or kidney disease, cancer, anemia, epilepsy, or mental illness.

Personal and Social History

Born and raised in Lake City, finished high school, married at age 19. Worked as sales clerk for 2 years, then moved with husband to Amarillo, had 3 children. Returned to work 15 years ago because of financial pressures. Children all married. Four years ago Mr. N died suddenly of a heart attack, leaving little savings. Mrs. N has moved to small apartment to be near daughter, Dorothy. Dorothy's husband, Arthur, has an alcohol problem. Mrs. N's apartment now a haven for Dorothy and her 2 children, Kevin, 6 years, and Linda, 3 years. Mrs. N feels responsible for helping them; feels tense and nervous but denies depression. She has friends but rarely discusses family problems: "I'd rather keep them to myself. I don't like gossip." No church or other organizational support. She is typically up at 7:00 a.m., works 9:00 to 5:30, eats dinner alone.

■ Exercise and diet. Gets little exercise. Diet high in carbohydrates.

■ Safety measures. Uses seat belt regularly. Uses sunblock. Medications kept in an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet below sink. Mr. N's shotgun and box of shells in unlocked closet upstairs.

Review of Systems

*General. Has gained about 10 lb in the past 4 years. Skin. No rashes or other changes.

Head, Eyes, Ears, Nose, Throat (HEENT). See Present Illness. No history of head injury. Eyes: Reading glasses for 5 years, last checked 1 year ago. No symptoms. Ears: Hearing good. No tinnitus, vertigo, infections. Nose, sinuses: Occasional mild cold. No hay fever, sinus trouble. *Throat (or *mouth and pharynx): Some bleeding of gums recently. Last dental visit 2 years ago. Occasional canker sore.

Neck. No lumps, goiter, pain. No swollen glands.

^ Breasts. No lumps, pain, discharge. Does self-breast exam sporadically.

Respiratory. No cough, wheezing, shortness of breath. Last chest x-ray, 1986, St. { Mary's Hospital; unremarkable.

^ Cardiovascular. No known heart disease or high blood pressure; last blood pressure taken in 1998. No dyspnea, orthopnea, chest pain, palpitations. Has J never had an electrocardiogram (ECG).

( *Gastrointestinal. Appetite good; no nausea, vomiting, indigestion. Bowel movement about once daily, though sometimes has hard stools for 2 to 3 days when especially tense; no diarrhea or bleeding. No pain, jaundice, gallbladder or liver problems.

*Urinary. No frequency, dysuria, hematuria, or recent flank pain; nocturia x 1, f large volume. Occasionally loses some urine when coughs hard.

Genital. No vaginal or pelvic infections. No dyspareunia.

Peripheral Vascular. Varicose veins appeared in both legs during first pregnancy. For 10 years, has had swollen ankles after prolonged standing; wears light elastic pantyhose; tried "water pill" 5 months ago, but it didn't help much; no history of phlebitis or leg pain.

Musculoskeletal. Mild, aching, low-back pain, often after a long day's work; no radiation down the legs; used to do back exercises but not now. No other joint pain.

Neurologic. No fainting, seizures, motor or sensory loss. Memory good.

Hematologic. Except for bleeding gums, no easy bleeding. No anemia.

Endocrine. No known thyroid trouble, temperature intolerance. Sweating average. No symptoms or history of diabetes.

Psychiatric. No history of depression or treatment for psychiatric disorders. See also Present Illness and Personal and Social History.

Physical Examination

Mrs. N is a short, moderately obese, middle-aged woman, who is animated and responds quickly to questions. She is somewhat tense, with moist, cold hands. Her hair is fixed neatly and her clothes are immaculate. Her color is good and she lies flat without discomfort.

Vital Signs. Ht (without shoes) 157 cm (5'2"). Wt (dressed) 65 kg (143 lb). BP 164/98 right arm, supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6°F.

Skin. Palms cold and moist, but color good. Scattered cherry angiomas over upper trunk. Nails without clubbing, cyanosis.

Head, Eyes, Ears, Nose, Throat (HEENT). Head: Hair of average texture. Scalp without lesions, normocephalic/atraumatic (NC/AT). Eyes: Vision 20/30 in each eye. Visual fields full by confrontation. Conjunctiva pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally, reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhages, exudates. No arteriolar narrowing or AV nicking. Ears: Wax partially obscures right tympanic membrane (TM); left canal clear, TM with good cone of light. Acuity good to whispered voice. Weber midline. AC > BC. Nose: Mucosa pink, septum midline. No sinus tenderness. Mouth: Oral mucosa pink. Several interdental papillae red, slightly swollen. Dentition good. ^ Tongue midline, with 3 x 4 mm shallow white ulcer on red base on undersurface £ near tip; tender but not indurated. Tonsils absent. Pharynx without exudates.

Neck. Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.

Lymph Nodes. Small (<1 cm), soft, nontender, and mobile tonsillar and posterior cervical nodes bilaterally. No axillary or epitrochlear nodes. Several small inguinal nodes bilaterally, soft and nontender.

Thorax and Lungs. Thorax symmetric with good excursion. Lungs resonant. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.

Cardiovascular. Jugular venous pressure 1 cm above the sternal angle, with h■ head of examining table raised to 30°. Carotid upstrokes brisk, without bruits. fl Apical impulse discrete and tapping, barely palpable in the 5th left interspace,

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