William Fredericks42 y/o male6’0’’ (183 cm)215.0 lbs (97.7kg)Reason for encounter: worsening headaches and facial pain, feverHx:Hx of present illness:OLDCARTS mnemonicOnset:Loca琀椀on:Dura琀椀on:Characteris琀椀cs:Aggrega琀椀ng:RelievingTreatmentSeverityPMH:HTN: 6 YEARS, Hypercholesterolemia x 6 years psoriasis since childhoodSx hx: appendectomy at 29 y/o hospitaliza琀椀on appendectomyMedica琀椀ons: Hctz 25 mg po DAILyMul琀椀vitamin daily OTC as neededTylenol ES Tylenol cold and 昀氀u advil naproxenAllergies:grass, trees. Seasonal pollen, dust & mold with symptoms of itchy watery eyes, scleralinjec琀椀ons, sneezing, runny nose, nasal conges琀椀onPreventa琀椀ve health:Fitness, no exercise rou琀椀ne except for ac琀椀vey on job nutri琀椀on: typeical American diet high in meats andcarbs,Stress reduc琀椀on: nothing works 50+ hours a weekDaily sleep 6-7 hrs with addi琀椀onal on weekendslOMoARcPSD|13778330
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