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1 NUR 2231: The Diagnostic Physical Examination Across the Lifespan Sample Written History and Physical Exam Date Onset 6/2008 2002 1995 1993 Problem List Active Problem Inactive Problem Pneumonia D&C-­‐spontaneous ab Penicillin Allergy C-­‐Section Tobacco Abuse L Meniscus tear-­‐arthroscopy Tension Headaches Date Resolved 2004 2002 1992 Health Risk Profile Risk Factor Tobacco Abuse Sedentary Lifestyle Behind on Immunizations L Meniscus Tear Military Career Stress FH + DM, HTN, MI Problem for Which at Risk ASHD COPD Lung, bladder, cervical cancer Pneumonia Obesity Inability to manage stress CV disease Dyslipidemia Type II DM Tetanus Injury Osteoarthritis Chondromalacia Stress Occupational chemical/infectious exposure Travel related diseases such as malaria Depression/Anxiety Heart Disease Compromised immunity ASHD HTN DM CVA Renal Disease Retinopathy Dyslipidemia NUR 2231: The Diagnostic Physical Examination Across the Lifespan 2 CC: 34 year-­‐old African-­‐American female, active duty Navy E-­‐7, presents with complaint of “I can’t stop coughing” for the last two weeks. HPI: The patient was in her usual state of health until two weeks prior to this appointment when she noticed the gradual onset of cough. Initially her cough was intermittent and non-­‐
productive, with no associated dyspnea. However, over the next several days she noted the cough becoming more frequent, and became productive of clear sputum. At this time, she also noted the onset of generalized malaise, feeling intermittently warm and cold, and a having a few chills. Seven days prior to presentation, a physician prescribed a course of doxycycline. However, over the ensuing week, she noted further worsening of her cough, which is now almost constant and keeps her from sleeping. She also notes her sputum is now yellow and occasionally green, of which she brings up several tablespoons daily. She denies any bloody or rust colored sputum. Approximately 3 days ago the cough became associated with some stabbing pain over the right lateral chest that has persisted, and states it is non-­‐radiating and worse with deep inspiration. She denies any exertional chest pain or dyspnea, but has stopped exercising, and has been minimally active since becoming ill. Two days prior to this appointment she had experienced nausea and poor appetite that has since persisted. She has vomited twice, with the last episode this morning, but is still able to keep down liquids and small quantities of bland foods. She has no associated abdominal pain or diarrhea. The patient presented for evaluation today because “I’m just not getting better”. She has tried echinacea as well as Nyquil, but has not had any relief from the cough. Of note, she traveled to Singapore and the Persian Gulf six months previously, but does not report any recent sick contacts and has been well since returning. She denies any exposure history for tuberculosis or HIV, and received a flu shot in October and had a negative PPD at that time. She denies any history of asthma or previous pulmonary infections, but does have a 13 pack/year smoking history. Past Medical History: CHD: +varicella; negative for rubella, rubeola, mumps, scarlet or rheumatic fever. Other illnesses: denies TB, STD, hypertension, DM, cancer, mental illness CVA, thyroid, heart, lung, liver, kidney disease; Hospitalizations/ Surgeries: D&C, 2004. After a spontaneous fetal loss. Uncomplicated procedure. Magee Women’s Hospital Caesarean section 2002 for breech position. Healthy baby delivered after an uncomplicated procedure. Magee Women’s Hospital NUR 2231: The Diagnostic Physical Examination Across the Lifespan 3 Arthroscopic surgery, 1992. Repair of her left medial meniscus after a skiing injury. She was admitted overnight because of a fever, but had an uneventful recovery otherwise. Montifiore Hospital Medications: Doxycycline 100mg twice daily. Completed 7 of 10 days. Reports good adherence with no missed doses Ibuprofen 200 mg 1-­‐2 times per month prn headache Echinacea (dose unknown) 2 tablets tid for two weeks since becoming ill Nyquil one teaspoon qhs for three days No use of other herbal or OTC medications. No history of sleep medications, vitamins, or supplements. Allergies: PCN-­‐ rash and urticaria . No known food or environmental allergies Injuries: Patient reports left medial meniscus injury (see Past Surgical Hx). Otherwise, no significant trauma history Primary Care Provider: Sees Cynthia Jackson, FNP-­‐BC at Get Well Soon Health Center. Last appointment was 4/2008 for a check-­‐up after returning from the Persian Gulf Rates health as good. Gynecologic/Obstetrical History: • Menarche age 12 Periods regular q30 days last 5 days LMP two weeks ago • G3P2SA1 First child by SVD (age 23) Second child by C-­‐section 2 lifetime partners Denies hx STD, cysts, ectopic pregnancy, abnormal pap smears Contraception: Diaphragm. Monogamous relationship per patient Family History: Both parents are alive and in fair health. Father (59):type 2 diabetes and hypertension. Mother (60):“rheumatism” and hypertension. Two older brothers ages (36, 28): both in good health. Two children (ages 8,11) are well. Paternal grandfather: deceased age 92 CVA Maternal grandmother deceased age 81 MI No history cancer, TB, psychiatric disorders, kidney, thyroid, lung disease. Social History: NUR 2231: The Diagnostic Physical Examination Across the Lifespan 4 Social Support: Married since age 20 to another active duty member who is also 34 y/o and in good health. Stationed together this tour in base housing, but families live on the west coast. States marriage is stable, children doing well. States sexual activity occurs less frequently than desired (once or twice/month) due to fatigue and stress from jobs. Pt and spouse are beginning to schedule “dates” Denies any form of mental, physical, verbal abuse Spouses have been deployed at separate times so children have one parent available. If should be deployed together, children would go to west coast to be with maternal aunt. Pt admits to having stressed when she or husband is deployed and one parent is available however, she has a network of friends at the base who help each other. Alcohol: Drinks 1-­‐2 servings of wine or beer about twice a month. C (-­‐) A (-­‐) G(-­‐) E(-­‐) Illicit Drugs: Denies Smoking: Smokes ~1 ppd of cigarettes only since age 21 (13 pack-­‐years). She has been interested in cessation in the past, but is concerned about gaining weight. Occupation: Has served 16 years of enlisted duty in the Navy, and currently works in intelligence in a supervisory role that she describes as a “high-­‐stress” environment. She was in the Persian Gulf for six months earlier this year. She has had two ship cruises during her career. No occupational exposure to inhaled toxins or sick contacts. Education: High school graduate with technical training obtained while in service. Finances: Denies financial concerns since both she and her spouse are in the military and while salaries are not high, benefits and housing help to provide stability. Health care covered by military benefits. Religion: Active in Church of God. Pt states she misses her church when she is deployed but practices her beliefs wherever she is. Diet: Eats three meals daily. “Normal” diet prior to illness without restrictions. Had tried the “Adkins” diet for weight loss a year ago, but has resumed her normal diet. No history of eating disorders. Exercise: Works out at the gym 2-­‐3 times weekly prior to “PT tests”, but is otherwise sedentary. Safety: Has one gun in home. Keeps in locked cabinet in attic with attic door locked. Wears seatbelts at all times. Helmet when she bikes. No motorcycles. Has carbon monoxide and smoke detectors on each floor of home. HEALTH MAINTAINANCE: Immunizations: Tetanus 1997. Flu shot and negative PPD in October 2007. Mammogram: Never been done. EKG: 2006 normal Pap: 3/08; normal NUR 2231: The Diagnostic Physical Examination Across the Lifespan 5 Glucose/Lipid: checked annually. Reports results have been “normal” Skin survey: Reports she has never had Eye exam: Wears glasses for myopia. Last eye exam 5/08 “normal” Dental exam: Annually, last 8/07 Blood pressure: Annually, last checked 4/08 and “normal” REVIEW OF SYSTEMS: Dermatologic: Denies pruritis, pigmentary changes, lesions, nail or hair changes, bruising Head: Denies trauma, “tension” headaches 1-­‐2 times/month-­‐unchanged over 15 years relieved with Ibuprofen 1-­‐2 times/month Eyes: + myopia, denies eye pain, excessive tearing, visual disturbance Ears: Denies hearing loss, ear pain, tinnitus or earaches. Nose & Sinuses: Denies nasal discharge, obstruction, epistaxis,sinus pain, pressure Throat/Mouth: Denies bleeding gingiva, ulcers, nodules, pain, ST, hoarseness, difficulty swallowing Breasts: Denies masses, pain, nipple discharge or retraction, dimpling, skin changes Respiratory: See HPI. Denies night sweats Cardiovascular: See PMH. Denies palpitations, PND, orthopnea, syncope, leg pain, edema, varicose veins, phlebitis, hx murmur Abdominal: See HPI, denies hematochezia, melena, hemorrhoids, jaundice Urinary: Denies frequency, urgency, dysuria, hematuria, incontinence, calculi Gynecological: Denies mennorrhagia, metrorrhagia, vaginal discharge/itching Metabolic/Endocrine: Denies unexplained weight change, fatigue, heat/cold intolerance, goiter, polydipsea, polyuria Musculoskeletal: Denies joint/back pain, stiffness, swelling, increased temperature, muscle weakness, myalgia. Neurologic: Denies syncope, seizures, vertigo, paralysis, tremors, ataxia, paresthesias LOC Psychiatric: Denies symptoms of anxiety or depression, mood swings, sleep disturbances, delusions, or hallucinations. PHYSICAL EXAM: Vitals: BP 137/72 right arm seated P 100, regular T 100.5 (otic) RR 18, regular, pulse ox 99% HT 67in Wt 134lb BMI 21 NUR 2231: The Diagnostic Physical Examination Across the Lifespan 6 General: Mildly ill appearing female who appears her stated age. Alert and conversant, becomes SOB when speaking more than two sentences. Patient is not using accessory musclest. Skin: No rashes appreciated. Keloid formation noted on right forearm scar. No suspect moles. Hair distribution normal, texture smooth. Nails without cyanosis, clubbing Head: Normocphalic Eyes: Conjunctiva non-­‐injected. No icterus. Sclerae clear. EOMI. Visual acuity 20/20 bilaterally with Snellen card. Pupils 5mm, reactive equally to light and accommodation; Funduscopic exam: discs sharp and flat. Normal venous pulsations. No Av nicking appreciated, retina without lesions Ears: Hearing intact to whisper test. TMs pearly gray with 4+ mobility, canals without erythema or exudate Nose: Mucosa moist, turbinates without erythema. No septal deviation/perforation. No polyps appreciated No sinus tenderness Mouth: Lips, tongue and buccal mucosa moist without lesions or masses. Dentition excellent. No gingival hypertrophy or obvious periodontal inflammation Throat: No erythema or exudates. No visible post-­‐nasal drip or cobblestoning. Tonsils symmetrical 2+. No masses seen Neck: Supple with full ROM. Trachea midline. Thyroid symmetrical. No enlargement, tenderness, no nodules, goiter, or bruit appreciated. Neck veins 3 cm above sternoclavicular joint at 30 degrees. Carotid pulsations equal b/l without bruits Lymphatics: No Preauricular, postauricular, occipital, tonsillar, submandibular, submental,ACN, PCN, supraclavicular, axillary adenopathy. 1-­‐2 pea-­‐sized mobile and non-­‐tender bilateral inguinal lymph nodes are present bilaterally Breasts: Nontender, no skin changes, masses, nipple d/c or retraction Chest: Symmetric chest excursions Lungs: Shallow respirations with apparent splinting. Tympany noted bilaterally. Increased tactile fremitus in the right posterior mid-­‐lung zones. Left lung clear to auscultation. Right lung with right mid-­‐lung coarse inspiratory and expiratory crackles. Egophony is present over this area. No wheezes or rubs appreciated. Cardiovascular:.. PMI on the mid-­‐clavicular line, 5th ICS. No heaves or thrills, S1 and S2 normal with physiologic S2 split. No S3 or S4. Precordium is quiet Abdomen: Soft, nontender. Well-­‐healed caesarean scar without keloids. Normoactive bowel sounds without renal or aortic bruits. Liver span 12 cm in mid-­‐clavicular line. Spleen non-­‐
NUR 2231: The Diagnostic Physical Examination Across the Lifespan 7 palpable and does not extend beyond ribs to percussion in right lateral decubitus position. No masses, guarding, rebound, ascites. Back: Spine without deformity. No vertebral or costo-­‐vertebral angle tenderness. Full ROM Extremities: Pulses: Radial, brachial, femoral, popliteal, dorsal pedal, posterior pedal 2/2 equal and symmetrical. No femoral bruits. No varicosities Joints: Full ROM, nontender, no edema, deformities, laxity, locking, dislocation or crepitus Neurological: Alert and oriented x3, Cranial nerves II-­‐XII intact (Please write for each CN how you would test it. For example, CN I recognizes common odors). Gait in tandem, Cerebellar: RAM, F-­‐N, H-­‐S intact, Romberg negative, no pronator drift. Sensation to pinprick, light touch, position, and vibration intact. DTRs: biceps 2+, triceps 1+, knee 2+, Achilles 2+ equal and symmetrical. No Babinski present. Pelvic: EG without lesions, atrophy. Vagina pink, moist, no lesions or d/c. Cervix: multiparous, firm, nontender, no lesions/erosions. Uterus, anteflexed, nontender, normal size. Adnexae: nontender, no masses or enlargement Rectal: Sphincter tone intact, no masses. 2 nontender external hemorrhoids noted at 6:00 and 8:00. Soft brown stool, hemoccult negative