Comprehensive History and Physical Examination

Comprehensive History and Physical Examination

Health History

Ms Tina Jones is a 28-year-old African American woman who presents to the clinic for her pre-employment physical. She is the primary source of information. She is oriented to person, place, and time. Her mood is pleasant, and she makes proper eye contact while interviewing. She is neatly dressed, has good hygiene, and appears well-nourished. She speaks clearly and audibly. She is sitting upright and seems comfortable and ready for her exam.

Tina reports that she has a medicine allergy to penicillin which gives her a rash. She also has a latex allergy. Ms Jones also has allergies to cats which will cause her to go into have asthma attacks, swollen eyes, and a runny nose. She also stated that dust can cause her to have asthma attacks. She states she keeps her house very clean and if she is exposed to cats she will go home immediately and take a shower which helps.

Ms Jones’s last exam was four months ago when she received her gynecological exam. There her GYN diagnosed her with polycystic ovarian syndrome and prescribed her contraceptive, YAZ. She takes it every morning with breakfast and tolerates it well. She has reported that her cramping is less, and her cycle is regular lasting five days since beginning her contraceptive. She also had a PAP smear which she is negative for STIs and HIV. She has never been married. She states that she is in a new relationship and that they plan on being sexually active, and she will use condoms.

When Ms Jones was the age of 2.5 years, she was diagnosed with asthma. She manages her asthma with inhalers such as; Albuterol 90 mcg/sprays MDI 2 puffs every four hours as needed and Fluticasone Propionate 110 mcg 2 puffs twice a day. She stated she was last hospitalized for an asthma attack in high school. Ms Jones has also never had to be intubated for her asthma.

At the age of 24, Ms Jones was diagnosed with type 2 diabetes. She has been controlling her diabetes with diet, exercise, and Metformin 850mg. She checks her blood sugar every morning. She stated when she first took metformin, it was upsetting her stomach, so she implemented yogurt into her diet, which has helped.

She also stated that she does not take any over-the-counter medications other than Ibuprofen 600mg for menstrual cramps and Acetaminophen as needed for her headaches, which she says are not as frequent. She does not take any herbal remedies or vitamins.

Ms Jones stated she thinks she is up to date with all her vaccines. She received all her childhood shots, and she received her tetanus booster last year. She never got the influenza vaccine. She states she has never had any surgeries. Her last eye exam was three months ago, and she was prescribed glasses to wear, which has helped her vision.

Ms. Jones reports a family history of diabetes, hypertension, and hyperlipidemia. Her mother has a history of hypertension and hyperlipidemia. Her father passed away in the last year at the age of 58 and had a history of hyperlipidemia, hypertension, and type 2 diabetes. Her sister has asthma, and her brother has obesity. Ms Jones reported that her maternal grandparents passed away both from stroke and had a history of hypertension and hyperlipidemia. Her paternal grandfather passed away from colon cancer; he had a history of type 2 diabetes. Her paternal grandmother has hypertension and is still alive. She states her paternal uncle suffers from alcoholism. Ms Jones reports there is no mental illness, thyroid disease, kidney disease, or other cancers in her family.

Ms Jones currently lives with her mother and sister. States that she will be moving out to be closer to her new job. She will begin working at Smith, Stevens, Stewart, Silver, and Company in the next couple of weeks. She does not smoke tobacco. Her last marijuana use was at the age of 21. She has never used any recreational drugs. She wears a seat belt. She drinks up to three alcoholic beverages about 2-3 times per month with friends.

For breakfast, she typically has a fruit smoothie and yogurt, or wheat toast and eggs. For lunch, she usually will have beans and brown rice, leftovers from dinner, or chicken/tuna salad on wheat bread. She will typically make chicken and vegetables or salmon and brown rice. Ms Jones will typically have apples or carrot sticks as a snack. She drinks 2 diet cokes per day.

Ms Jones states that she has not had any recent or frequent illnesses, fatigue, fevers, chills, or night sweats. She recently lost ten pounds due to dietary changes and exercise. She has not had any medication side effects and does not have any health concerns that she feels need to be addressed today.

Physical Examination

Upon assessment, Ms Jones’ vital signs are 37.2C, 128/82, 78, 15 and 99%. She denies a current headache. She also denies having symptoms of dry eyes, eye pain, or itchy eyes. She has no problems with her ears, no changes in her hearing. Ms Jones reports no change in her sense of smell, epistaxis, or sinus pain. She also denies problems with dry mouth, pain, sores, issues with her gums, or jaw pain. She does not have any difficulty swallowing or complains of a sore throat.

Ms. Jones’ head is evenly shaped, her hair is well put, and her scalp is clean and free of lesions. Her eyebrows are symmetric. No ptosis or edema was noted. Her pupils are brisk, round, equal, and reactive to light. Her conjunctiva is pink, and her sclera is white. Her eyesight is 20/20 with her new corrective glasses. She has pustules on her face. She also has facial hair on her upper lip. Her nose is symmetric and midline, her nares are patent, moist, and pink, and no lesions are noted. Her maxillary sinuses were nontender on palpitation. She has bilateral tympanic membranes that are intact and pearly grey with a positive light reflex. Whispered words exam reveals equal bilateral hearing. The oral mucosa is pink and has no lesions. The pharynx, uvula, and tonsils are pink, moist, and without lesions. Teeth are clean, white, and intact. The tongue is mobile and without lesions. The gag reflex is intact. Teeth are intact. No caries noted. The temporomandibular joint is smooth and symmetrical. The thyroid is nonpalpable. No goitre present. Lymph nodes of the neck are nonpalpable.

Ms. Jones reports no shortness of breath, wheezing, chest pain, dyspnea or cough. Upon assessment, her chest is symmetric with respirations. Her lung sounds are clear to auscultation bilaterally in all lobes. No adventitious sounds are heard. Resonance throughout with percussion of the chest. Her spirometry reading is FVC 3.91 L and FEV1 3.15. Her FEV1/FVC ratio is 80.56%.

Ms Jones denies palpitations, easy bruising, and edema. Her cardiac assessment reveals a regular heart rate. S1 and S2 are auscultated without murmurs, gallops, or rubs. Bilateral carotids are regular with no bruits. The upper extremities are warm, and skin color is normal. No lesions or oedema were noted. Fingernails are clear and pink. Capillary refill is less than three seconds bilaterally. Brachial and radial pulses are regular rhythm, +2, and equal bilaterally. Lower extremities are warm. Skin colour is normal. No lesions were noted. No oedema or varicosities. The toenails are clear and pink. Capillary refill is less than 3 seconds bilaterally. Femoral, tibial, and dorsalis tibialis pulses are +2, regular, and equal bilaterally. No lymphadenopathy. No bruits. PMI is at the midclavicular line, 5^th intercostal space. No heaves or lifts.

Ms Jones denies nausea, vomiting, abdominal pain, constipation, diarrhea, gas or bloating. She denies food intolerances. She reports no dysuria, hematuria, flank pain, or vaginal discharge. She states that she awakens once at night to use the restroom. Upon assessment, Ms Jones’ abdomen is large and symmetrical. The umbilicus is midline. Abdominal skin color is normal and without lesions. Coarse hair is noted from the pubis to the fundus. No bulges or ascites are observed. The abdomen is soft. Ms Jones is not guarded and does not complain of tenderness with palpation. Bowel sounds are positive in all four quadrants. No bruits are auscultated. Sounds are tympanic throughout to percussion. Liver span is 7 cm on MCL. The bladder and spleen are nonpalpable. No CVA tenderness is noted.

Ms Jones denies muscle and joint pain, muscle weakness or swelling. Upon assessment, no masses, lesions, edema or deformities are observed. The shoulders and clavicle are equal bilaterally.  Upper and lower extremities have full ROM and 5/5 muscle strength bilaterally. No pain with movement. Joints are nontender. The spine is midline and has full ROM.

Ms Jones reports no dizziness, lightheadedness, tingling, loss of coordination, or seizures. Assessment of Ms Jones’ neurological system reveals normal cerebellar function testing, graphesthesia, stereognosis, and rapid alternating movements bilaterally. Her upper and lower extremity deep tendon reflexes are equal and +2 bilaterally. She has decreased sensation to monofilament in her bilateral plantar surfaces.

Problem List

Risk factors for diabetes II include race, inactivity, family history, polycystic ovaries, and hypertension (Mayo Clinic, 2014). Family members share genes, behaviors, and lifestyles that have an influence on one’s health. Tina’s family history reveals a strong history of hypertension, hyperlipidemia, and type II diabetes. This risk factor alone has put Ms Jones at increased risk for developing diabetes. Family history is not a modifiable risk factor.

Since Ms Jones’ visit to the clinic following her foot injury months ago, she has made some modifiable changes, including changes to her diet, an increase in activity and compliance with medication, and checking her blood sugars. With these changes, Ms Jones’ health has improved. However, her medical problems list remains the same. Ms Jones’ problem list includes hypertension, diabetes, and peripheral artery disease.

Being overweight puts Ms Jones at risk for hypertension and diabetes. Ms Jones reported losing 10 pounds since her last visit. According to the AHA (2016), weight loss of five to seven percent of body weight can decrease the risks and complications of diabetes. Physical activity is the top modifiable risk factor for diabetes. Ms Jones reports exercising four to five times per week. High blood pressure is linked to diabetes. Both diseases share the same risk factors. Ms Jones’ lifestyle changes have helped her to maintain better control of her blood pressure without medication since her last visit. Ms Jones has demonstrated healthy lifestyle choices and changes, along with self-monitoring of her blood glucose. I would encourage her to continue with her regimen and continue with ongoing education and nutritional advice as necessary. She will require reviews and modifications to her treatment plan based on her progress, needs, and any changes that may occur.

Peripheral Artery Disease (PAD) occurs when blood vessels in the legs are blocked by fatty deposits, resulting in a decrease in blood flow to the lower extremities. Diabetics have an increased risk of developing PAD. Symptoms of PAD include leg pain, numbness, tingling, cool lower extremities, and slow-healing wounds to the lower extremities and feet (NHLBI, 2016). On assessment, Ms Jones displayed a decrease in sensation to the plantar surfaces of her feet bilaterally. If left untreated, PAD can result in heart attack, stroke, gangrene, and amputation. Bypass grafting, angioplasty, and atherectomy are some ways to correct or slow down the progression of Peripheral Artery Disease. Treatment for Ms Jones’ PAD symptoms would focus on interventions to prevent the progression of the illness. Ms Jones’ would be encouraged to maintain her blood pressure and blood glucose levels and continue with her physical activity. She will perform self-skin checks that assess for skin integrity, oedema, temperature, and decreased sensory perception. Ms Jones will report and monitor any injuries to her feet and know when to seek medical attention before the injury progresses.

Although she can’t change her race or family history, Ms Jones has proven that modifiable risk factors play an important role in maintaining and preventing the progression of diabetes and peripheral artery disease. Education and support help to make this achievable. Ms Jones is well-educated and understands the risks involved with her medical problems. She has a strong support system that consists of her mother and sister, with whom she lives. She is excited about her new job and new relationship. Satisfaction with her job and sustaining a healthy relationship will help her to have a positive outcome with her medical problems.

References

AHA (2016). Understand your Risk for Diabetes. Retrieved on December 5, 2016, from http://www.heart.org/HEARTORG/Conditions/More/Diabetes/UnderstandYourRiskforDiabetes/Unde rstand-Your-Risk-for-Diabetes_UCM_002034_Article.jsp#.

T Jones, personal communication, Shadow Health, May 2019.

National Heart, Lung and Blood Institute (2016). How is PAD Treated? Retrieved on December 5, 2016, from https://www.nhlbi.nih.gov/health/health-topics/topics/pad/treatment.

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