Past Medical History

  • Medical history: Uncomplicated birth, no hospitalizations.

  • Surgical history: None

  • Medications: None

  • Allergies: Penicillin (rash)

  • Family history: His father had diabetes and hypertension and died when patient was very young. His maternal grandmother died of breast cancer at age 76 years. There is no history of skeletal dysplasia or muscular dystrophy in the family.

  • Social history: Patient was born at 37 weeks' gestation via spontaneous vaginal delivery and had an uncomplicated postnatal course. He is in age-appropriate grade in school and doing well academically and behaviorally. On interview with the mother outside the room, the patient reports that he feels happy and supported at home with his mother and sisters. Patient reports that he has never tried alcohol, drugs, or cigarettes. He is not sexually active.

    The patient's family is from Guinea Bissau but the patient was born and raised in the United States and has not traveled outside the country. No known history of tuberculosis exposure. He is up to date on all vaccinations, and he received an influenza vaccine this year. He eats a normal diet, including fruits and vegetables, and drinks milk daily.