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Subjective Data:. Chief Complaint: Headaches On And Off

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Subjective Data: Chief Complaint: Headaches on and off for three days, routine monthly visits for hypertension, diabetes, and, glaucoma evaluations. History of Present Illness: Mr. A. O. a 66 year-old-African American male came in the clinic for a monthly routine follow up visit complaining of severe cluster frontal headaches that radiates to his left eye, pain level eight out of ten, on and off for three days lasting for 30 to 45 minutes. He stated that he takes Tylenol 1000mg orally every eight hours with mild relieve, and will like his blood pressure medications increased. Also, he complained of edema to the upper and lower extremities, and right hand pain when he tries to make a fist. However, he denied shortness of breath,…show more content…
Ears: Denies ringing in the ear or hearing impairment. Nose: Denies nasal discharge, congestion, or problems with his sense of smell. Throat: Denies problems with his gums and mouth. Swallows without any difficulty. Neck: Denies any edema or bruises around the neck. Respiration: Denies labored breathing. Cardiovascular: Denies chest pain, but complained of edema to the upper and lower extremities. Gastrointestinal: Denies anorexia, nausea and vomiting, heartburn, abdominal pain, or constipation. Endocrine: History of Type two diabetes, he stated that his blood before breakfast was 95. Objective Data: Vital signs: Temperature 98.7 Fahrenheit, BP 200/140 Pulse 80, Respiration 18, weight 345 IBS, BMI of 35. Generalized appearance unkempt and obese Skin: Warm to touch, dry and intact. Head: Normocephalic, Atraumatic. Ears: No discharge or cerumen noted bilaterally, tympanic membrane normal without redness or edema Nose: Nares patent without any obstruction. No frontal or maxillary tenderness during palpation of the sinus cavities. Pharynx: Oral mucus membrane moist, dental cavities and plague. No edema noted Neck: No palpable lump, carotids without bruit Cardiac: Regular rhythm without murmur, normal S1and S2. One plus edema to bilateral lower extremities. Capillary refills are presents and carotid bruits are absent. Respiratory: Lung sounds are clear on auscultation without rales, rhonchi, or wheezes. Respiration unlabored with
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