History & Physical, Coursework Example

Subjective: Geriatric Patient

Source and reliability: 78 year-old female

Chief Complaint: “having difficulty breathing, coughing, and pain in the chest area”

History of Present Illness: A 78 year-old female woke up at 5AM struggling to breathe, experiencing a wheezing cough, and feeling pain in the medial chest area. The patient has had similar trouble in the past, including a history of coughing fits and wheezing over a period of three months. She also stated that her throat feels somewhat raw from coughing so much and her lack of steady breaths is making her very tired. She requires further evaluation in order to determine a definitive diagnosis.

Past Medical History: Type 2 diabetes, mild hypertension, COPD, pneumonia (2009), chronic sinusitis

General state of health: Health is gradually declining due to chronic illness, limited mobility, and poor respiratory function

Past Illnesses: Type 2 diabetes, mild hypertension, COPD, pneumonia (2009)

Injuries: None

Hospitalizations: Brief visit to ED for hypoglycemia in 2012

Surgeries: None

Allergies: Cat and dog hair

Immunizations: Pneumococcal, influenza in late 2012

Substance abuse: Has an occasional glass of wine on the weekends

Diet: Consumes fruits and vegetables, bread, cereal, pasta; does not consume fast food and rarely eats out

Sleep Patterns: Sleep has been disrupted during coughing fits and when breathing is labored

Current Medications: Lisinopril 10mg, Albuterol, Ipratropium, Glipizide

Alternative therapies: None

Health Maintenance: Annual physical, quarterly examination with primary care physician to measure blood sugar, blood pressure, COPD evaluation by pulmonologist

Occupational and environmental history: Retired from teaching junior high after 39 years

Family history: Married for 42 years, husband still living, 3 daughters and 1 son

Psychosocial and spiritual history: Generally happy and content, enjoyed teaching, no history of depression, practicing Catholic

Sexual, reproductive, obstetric and gynecologic history: Gave birth to 3 daughters and 1 son via natural childbirth; no other complications

Review of Systems:

General: Has not been feeling well for several days

Skin: No visible rashes or other marks

Head: No unusual markings, hair is thinning but full

Eyes: No changes in vision, wears glasses, occasional watery eyes

Ears: No hearing concerns

Nose: Mild nasal congestion, runny nose

Mouth and throat: Persistent cough, raw throat from coughing

Neck: No visible signs of lumps or swelling

Chest: Moderate congestion, labored breathing

Cardiac: Mild chest pain from excessive coughing, no heart palpitations

Vascular: No visible bruises on legs or arms; mild bruising in chest area

Breasts: No lumps or visible marks

GI: No constipation; difficulty in swallowing due to raw throat; has increased fluid intake
Urinary: No frequency of urination or other concerns

Genitalia: No exam required

Musculoskeletal: No muscle aches

Neurologic: No memory loss

Objective data

General appearance: Fatigued yet alert, weight appears normal, hunched posture

Vital signs: temp 35.8, pulse 81, bp 135/82

Skin: no visible rashes, skin is dry yet warm

Head: no visible marks

Eyes: PERRLA, EOM complete

Ears: No redness or tenderness

Nose: Nasal congestion, runny nose

Sinuses: Chronic sinusitis

Pharynx: No concerns

Neck: No swelling or lumps

Lungs: Crackles and wheezes, shortness of breath

Heart: no JVD

Breasts: No lumps or bruising

Vascular: No visible edema

Abdomen: Normal bowel sounds, abdomen soft

Genitalia: No exam required

Rectum: No exam required

Lymphatic: No visible swelling

Musculoskeletal: Slouched posture, no joint disfiguration

Neurologic: Alert and oriented

In office labs or diagnostic tests: Na 134, K 4.4, Ca 9.0, Mg 1.3, CO2 19

Assessment

Diagnosis: Exacerbation of COPD symptoms caused by sinus infection, further complicating breathing and the ability to perform routine physical activities until the symptoms have subsided.

Plan:

Dx: Sinus infection, COPD symptom flare-up

Tx: Augmentin oral 875 mg

Pt.Ed/Referral/Follow-up: 7-10 days to examine O2/CO2 levels

Health maintenance: Reduced physical activity until symptoms subside, increased fluid intake, adequate rest

Subjective: Adolescent patient

Source and reliability: 16 year-old female

Chief complaint: “I have had terrible cramps for the past 3 days and can barely get out of bed”

History of present illness: A 16 year-old female was admitted to the ED for severe cramping in the lower abdomen over the past 72 hours. Patient is clutching her abdomen and experiences sharp pains during the examination at which time she winces and expresses her frustration with her situation. She is concerned about her cramps and is tired of feeling uncomfortable and limited in her movements.

Birth history: Born at 38 weeks, 6 lb. 2 oz., 20 inches long via cesarean

Past medical history: History of dysmenorrhea since periods began at age 13; broken wrist at age 12, chronic ear infections ages 3-6

Nutrition: No known food allergies, occasional fast food in diet

Growth and development: Normal growth and development; no known physical or mental disabilities

Immunizations: Influenza: 8/12, HPV: 9/12, chicken pox: 3/98, mumps: 3/98, measles: 3/98, tetanus: 3/98

Social and environmental (HEADSS): Stable home environment, both parents in household, 2 younger sisters, currently enrolled in 11^th grade, part-time job at pizza restaurant, participates in cross country, softball, no known drug use, not yet sexually active, no history of depression or suicide

Family history: Father: age 42, no serious health concerns, Mother: age 41, type 2 diabetes

Review of systems

General: Physical appearance not unusual

Skin: No visible rashes

HEENT: no visible head concerns, no changes in vision, wears contacts, no ear concerns, no visible nasal congestion, redness or swelling, no difficulties swallowing or tenderness in throat

Heart: No palpitations, no chest pain

Respiratory: No labored breathing, no cough

Abdomen: Severe abdominal pain, constipation, no vomiting

GU: Dysmenorrhea, no frequency of urination, no vaginal discharge, no other abnormalities

Skin: Skin is dry

Musculoskeletal: No muscle or joint pain, no gait problems, able to tolerate exercise

Neurologic: Mild headache, anxiety, nervousness, frustration, no dizziness or convulsions

Objective data:

General appearance: Appears stressed and in obvious discomfort; skin is pale

Vital signs: temp 36.0, pulse 82, bp 117/75

Skin: Skin dry yet no visible marks; skin is cold

Head: no visible concerns

Eyes: No visible concerns

Ears: No redness or swelling

Nose: No redness or drainage

Sinuses: No known history of sinusitis

Pharynx: No visible lumps

Neck: No visible markings or swelling

Lungs: Clear breath sounds, no crackling

Heart: No palpitations, normal pulse

Breasts: Mild tenderness in both breasts

Vascular: No edema

Abdomen: Distended and tender abdomen

Genitalia: No visible concerns

Rectum: Did not examine

Lymphatic: No swollen lymph nodes

Musculoskeletal: No muscle pain or swelling

Neurologic: Mild headache,

In-office labs or diagnostic tests: Na 1346, K 4.6, Ca 9.2, Mg 1.5, CO2 23

Assessment:

Plan:

Dx: Severe dysmenorrhea resulting in abdominal pain and constipation

Tx: Lo Ovral Oral 1x daily; Ibuprofen 400 mg as needed

Pt.Ed./Referral/Follow-Up: 7 days if cramps have not subsided

Health Maintenance: Rest, fluid intake, proper diet, heat when cramping is excessive

References

French, L. (2005). Dysmenorrhea. American Family Physician, 71(2), 285-291.

Medline Plus (2013). Painful menstrual periods. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003150.htm

The New York Times (2013). Chronic Obstructive Pulmonary Disease: complications. Retrieved from http://health.nytimes.com/health/guides/disease/chronic-obstructive-pulmonary-disease/complications.html

WebMD (2013). COPD (Chronic Obstructive Pulmonary Disease) – Medications. Retrieved from http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-medications