History and physical examination
Name: Mrs. Tiffany Jones
Referring physician: Self-referred, seems reliable
Chief Complaint: “I have been having severe headaches for the last two days.”
History of Present Illness (HPI)
For the previous five days, Mrs. Jones has been experiencing frontal headaches. She describes the pain as bifrontal, throbbing and moderately severe. The pain began after a minor accident when she slid from a ladder and fell and hit her head. The accident was minor states that she did not see the need for review. She has been taking Tylenol as painkillers, but it is no longer effective. The headaches are not associated with nausea and vomiting. The pain is aggravated by activity and is relieved by rest and put a damp towel on her forehead. The patient denies associated paresthesias, motor-sensory deficits or visual changes.
Medications: Tylenol 400 mg 1 tablet after 4-6 hours
Allergies: Aspirin causes gastrointestinal discomfort
Tobacco: About five cigarettes per day (Since the age of 18)
Alcohol: Takes wine on rare occasions
Past Medical History (PHM)
Childhood illness: Chickenpox, Mumps, Measles
Adult Illness: None
Surgeries: Tonsillectomy at age 6
Ob/GYN: G200P2, normal vaginal deliveries, two living children. Menarche at the age of 13years and LMP a month ago. Not sexually active, No psychiatric disorders.
Health maintenance: Not up to date
Father died at age 46 in an accident. Mother is 67 alive and diagnosed with dementia. She has one brother 30 years old, alive and healthy. Her two daughters age 6 and four years are alive and healthy. No family history of TB, diabetes, cancer, or cardiovascular disease.
Physical examination: Psychosocial History
She is born and raised in Deltroit, finished college and married her high school boyfriend. She works as a librarian in a nearby college. She lives with her family in their mortgaged house. She gets little exercise but is watchful of her diets. She feeds on homemade foods only. She uses seat belt regularly and sunscreen lotions.
Review of System
General: Denies fever, night sweats or chills
Skin: Pale and dry. Patient denies bruising rashes or skin discolorations
Eyes: Patient use corrective lenses
Ears: No ear pain, discharge or any hearing changes
Nose/Mouth/Throat: No sinus complication, no nose bleeds, no dysphagia, or throat pains
Heme/lymph/ Endo: No anemia or bleeding issue. No swollen glands. She does not feel excessive thirst or present cold intolerances
Cardiovascular: She denies orthopnea, peripheral edema or chest pains
Respiratory: She denies SOBs, wheezing, dyspnea or hemoptysis. She has no history of TB or pneumonia
Gastrointestinal: Denies NVD, has no abdominal pains, constipation or hemorrhoids. Denies eating disorders
Genitourinary/Gynecological: no hematuria, no night-time urination or changes in urine quantity
Musculoskeletal: Denies muscle pains, has mild back aches, no history of fractures of osteoporosis
Neurological: No seizures or syncope of transient paralysis
Psychiatric: No distress, no depression, psychosocial disorders or suicidal thoughts.
Vital signs: Height 5’2”, Wt 143lb, BMI 39.0, Bp 130/70 right arm seated, HR 88, RR 18, t 98.6F
General Appearance: Patient is alert and oriented. Denies acute distress, she is well groomed and generally healthy
Skin: Skin is intact, pale and dry. No bruising, rashes or lesions
Head: Normocephalic and atraumatic
Eyes: Intact EOMs and PERRLA, no sclera infection or lesions
Ear: Positive reflex, no discharge, infection or foreign bodies, visible umbo and short process
Nose: bilateral canals, no rhinitis in both nares, oral pharyngeal mucosa is pink, moist and not erythmatous. No dental prosthesis, nodules or thyromegally.
Cardiovascular: S1 and S2 is heard with normal and regular rate, no peripheral edema, no murmurs or edema
Respiratory: No chest pain, wheezing, or un-labored respirations
Gastrointestinal: abdomen soft and non-tender, No palpable masses, no abdominal pain, normal bowel sounds, no change in elimination frequency or change of color.
Breast/Chest: no lymphadenopthy, nipples with no discharge, chest unremarkable
Genitourinary: Bladder is non-distended, no hematuria or dysuria, no changes in urine color or elimination frequency
Musculoskeletal: Normal gait, good stability, no complaints of foot pain or edema
Neurological: Clear speech, good tone and posture normal and erect. Intact cranial nerves II to XII
Psychiatric: Well groomed, alert and oriented, maintained eye contact and answers questions appropriately.
Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Mosby (ISBN: 978-0-323-11240-6).
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