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Complete History & Physical Without Chief Complaint
Name: Sarah Jones Address: 1 Star Blvd., Excel, Arizona Age/DOB: 55/2-29-48 Gender: female Race: Caucasian Source of info/reliability: self/appears reliable
CC
Here for physical to establish self as patient. No current complaints.
HPI: not applicable.
PMH
Adult medical illness
Seasonal allergies since childhood
Asthma since 1980
HTN since 1999
Carpal tunnel syndrome 1998
Surgery -
Cholecystectomy 1988.
Carpal tunnel release, right wrist, 2000
Bunionectomy, left, 1995
Childhood illnesses-
Chicken pox and mumps
Trauma-
Fractured left arm age 12. No complications.
Head concussion from car accident age 18 - no complications.
RECENT EXAM/TESTS
Dental exam - 12/02 for cleaning
Full physical 6/02, no changes
Pap smear 6/02 - negative.
Mammogram 6/02 - negative.
CXR 6/02 - chronic changes of asthma, no interval changes.
EKG 6/02 - normal
Eye exam 2001 - new eyeglass prescription
Screening colonoscopy - none.
PFTs - none.
MEDICATIONS
HCTZ 25 mg QD
Albuterol MDI 2 puffs QID PRN
Multivitamin QD (contains calcium)
Calcium 500mg BID
ALLERGIES
Codeine causes systemic pruritus.
SOCIAL HISTORY
Place of birth, place of residence- Richmond, Va. Moved to Phoenix, AZ age 7.
Education/Occupation/religion - BSN, Registered nurse, works 12-hour day shifts in ICU. Non-practicing Catholic.
Marital status - divorced 10 years ago after 17 years of marriage. Lives alone, has a short-haired terrier dog. Has two sons - both live out of state
Sexual orientation - Heterosexual. No intimate relationships X 10 years.
Smokes - -1 PPD X 10 years. Quit 1980 when diagnosed with Asthma.
Alcohol - 4 ounces white wine 2-3 x per week with dinner.
Drug use - denies history of IVDU, or abuse of other non-prescribed or prescribed drugs.
Exercise - none routinely. Enjoys quilting.
Diet - eats all food groups, few fruits or vegs. Snacks on high carbohydrate "junk food" t/o workday Coffee 4-5 cups/day; 1-2cups of water/day
Living will/Medical POA - does not have.
IMMUNIZATIONS & TRAVEL (foreign only)_
Completed childhood series. Td- 1990; Hep B series with positive titre 1989; Hep A series 1996; annual PPD- neg 4/2003; annual Fluvax- most recent 10/2002. No Pneumovax.
FAMILY HISTORY (FH):
Maternal grandfather - died age 40 in WWII. No known medical hx.
Maternal grandmother - died age 78 of pneumonia following hospitalization for CVA
Paternal grandfather - died age 69 of AMI Hx of HTN
Maternal grandmother - died age 52 in MVA, hit by drunk driver.
Father - age 78, is overweight, has HTN, hyperlipidemia, emphysema.
Mother - age 75, DM2 since age 70.
Sister - age 51, overweight, no known medical problems.
Sons - age 23 & 26, no known medical problems.
Denies FH of cancer, psychiatric illness, colon, kidney, endocrine, or MSK disease.
ROS
Gen health: considers self in good health except for weight.
HEENTN: headaches once or twice a month, relieved with Tylenol, attributed to stress from job. Wears glasses whenever awake. Denies diplopia, blurred vision, eye pain or redness, loss of visual field, hearing loss, tinnitus, vertigo, sinusitis, postnasal drip, nasal polyps, epistaxis, problems with teeth/gums, dentures, mouth ulcers/growths, sore throat, hoarseness, change in voice, neck lumps or tenderness.
Pulm: Asthma symptoms of SOB and wheezing with exposure to smoke or flowers, relieved with inhaler, none with activity, no increased occurrence when HCTZ started. Denies cough, sputum, hemoptysis, dyspnea, pleuritic chest pain, recurrent infections, occupational exposures. Sleeps 6-8n hours per night.
CV: Takes BP once or twice a week at work, readings 132-138/82-86. Denies chest pain or pressure, palpitations, orthopnea, PND, SOB, pedal edema, heart murmur, varicose veins, cramping.
GI: Has BM every other day. Denies wt gain/loss, nausea, vomiting, diarrhea, constipation, hematemesis, melena, BRBPR, change in stool caliber, hemorrhoids, dysphagia, belching or flatus, Abd pain, change in appetite, hernia.
GU: Menarche age 12, regular monthly cycles until LMP age 51. G2P2. Not sexually active X 10 years. SBE on the 15th of every month. Denies postmenopausal bleeding, vag discharge, STD's, DES exposure, breast lumps, nipple discharge, dyspareunia, sexual dysfunction, dysuria, hematuria, nocturia, frequency, polyuria, incontinence, UTI's.
Neuro: Denies dizziness, syncope, seizures, vertigo, paresthesias, weakness, tremor, memory disturbance.
Rheum: Denies joint stiffness or swelling, myalgias, back pain. No right wrist pain or weakness since CTR.
Endo: Denies temperature intolerance, polyuria, polydipsia, polyphagia
Heme: Denies ease of bruising or bleeding, prior transfusions, lymph node enlargement, fatigue, fever, chills, night sweats. Blood type unknown.
Derm: Denies rashes, changes in moles or pigmentation, birthmarks, skin dryness, pruritus, lumps, changes in hair or nails.
Psych: Denies depression, agitation, panic/anxiety, manic episodes, personality changes, hallucinations.
OBJECTIVE
VS: Wt.- 155 Ht.- 5'5 BMI - 26 BP - 126/ 82 P - 78 T- 98.4 R -18
Gen: Healthy appearing 55 y/o white female who appears her stated age, in NAD.
HEENTN: normocephalic, atraumatic, head erect. Scalp without rashes, lesions, tenderness. Hair evenly distributed, fine texture. Sclera white, conjunctiva clear; No lid lag,. Ocular fundi with sharp disc margins, no arterial narrowing or AV nicking. Pinnae symmetrical without lesions. External canals with scant cerumen. TMs intact w/cone of light 4 o'clock right and 8 o'clock left. Nasal mucosa pink without lesions. Septum midline. Oral mucosa, tongue, gingiva moist, pink, without lesions. Teeth intact with evidence of repair, no obvious decay. Tongue midline without fasciculations. Posterior pharynx clear, tonsils 1+, without redness or exudate. Trachea midline. Thyroid non-palpable, non-tender. Carotids 2+ without bruit. No JVD. Pre & post auricular, occipital, tonsillar, anterior/posterior cervical, submandibular, submental supraclavicular, infraclavicular nodes non-palpable, non-tender.
Resp: AP diameter 2:1. Equal expansion. Respirations non-labored. Lungs CTAB anteriorly and posteriorly with good air movement t/o. No chest wall tenderness. CV: RRR, S1S2 without murmurs, S3S4, rubs, heaves or thrills. PMI L5ICSMCL. Radial, brachial, femoral, popliteal, DP, PT pulses 2+, equal. No varicose veins or abnormal pigmentation. No clubbing, cyanosis, or edema. CR <3 sec. Abd: Round, non-distended, no pulsations or lesions. Well-healed surgical scar RUQ. Bowel sounds present X4. No abdominal aortic, renal or iliac bruits. Soft, non-tender without palpable liver, spleen, kidneys, hernias. No CVAT.
GU: Breasts- inspected in 4 positions. No hyperpigmentation, lesions, abnormal hair distribution, nipple retraction or discharge, masses, dimpling, or tenderness. Axillary, pectoral, and epitrochlear nodes non-palpable, non-tender.
Pelvic: Tanner stage V, symmetrical hair distribution. No external lesions. Inguinal nodes non-palpable, non-tender. BUS non-swollen, nontender. Vaginal mucosa pink, dry, atrophic. Parous cervix is smooth, without lesions or ectopy. No cystocele, rectocele. Uterus NSSC, mobile, non-tender. Adnexa non-palpable, non-tender. RVE reveals intact sphincter tone and rectal wall, no lesions or masses, stool brown and guaiac neg.
MSK: Erect posture. Faint well-healed surgical scars right anterior wrist and left first MTP joint. TMJ, spine, neck, shoulders, elbows, wrists, fingers, hips, knees, ankles, toes with full AROM. Muscle strength 5/5 in biceps, triceps, deltoids, quads, hamstrings; no atrophy. No kyphosis, scoliosis, deformities, crepitus, heat, erythema, swelling or tenderness.
Derm: Skin intact, pink, dry, warm. Turgor without tenting. No rashes, scaling or lesions.
Neuro: Mental Status: 28/30 on MMSE- two incorrect serial calculations. Alert, attentive, pleasant and cooperative, coherent thought.
Cranial nerves:
I Olfactory identifies coffee and peppermint
II Optic Visual fields intact. Visual acuity 20/80 bil, corrected
III Oculomotor/ IV Trochlear/ VI Abducens PERRLA. EOM's intact without nystagmus, ptosis
V Trigeminal facial sensation intact 3 zones, temporal & masseter muscle strength 5/5
VII Facial Facial movement symmetrical
VIII Acoustic hearing intact to whisper at 5 feet, Weber without lateralization, Rinne AC>BC bilat.
IX & X Glossopharyngeal / Vagus Uvula midline with symmetrical rise on phonation, gag reflex intact, swallow intact
XI Spinal accessory - sternocleidomastoid & trapezius strength 5/5
XII Hypoglossal - Tongue movement symmetrical, strength 5/5
Motor: Smooth fluid gait. No pronator drift. Romberg neg. No involuntary movements. Rapid
alternating movements intact.
Sensory: Distinguishes sharp from dull, senses temperature, vibration and fine touch in
UE and LE. Proprioception, point localization, two-point discrimination, stereognosis,
graphesthesia intact.
Reflexes: biceps, triceps, brachioradialis, patellar, abdominal, Achilles all 2+.
Babinski
ASSESSMENT
1) HTN controlled with meds
2) Asthma controlled with meds.
3) Overweight
4) Post Menopausal
Complete H & P Without Chief Complaint
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