Comprehensive Health Assessment and Physical Assessment

Comprehensive Health Assessment and Physical Assessment

Patient Details:

Name: VO

Gender- Male

Age: 56 years

African American (Nigerian)

Photographer (occupation)

1. A. PROBLEM LIST
2. Active problems: blurry vision, farsightedness, headache, eye-straining
3. Inactive problems: elevated blood pressure, elevated blood sugar, premature presbyopia,
4. Risk factors: smoking (1.1 pack-years), alcohol intake, diabetes mellitus type II, hypertension, medication (HCTZ), genetic risk/ familial component
5. B. SUBJECTIVE DATA

Chief Complaint – I can’t read very well even with my eye-glasses

History of Presenting Illness: VO is a 56-year-old African American photographer who presents to the clinic with complaints of inability to read very well with or without his eyeglasses. He has been having problems reading small prints that he could read with his glasses about a half-decade ago. Whenever he tries to read newspapers or books at a close range, he develops a moderate frontal headache thereafter for which he has to take over-the-counter pain relievers. He, therefore, has to move the objects at armlength to read them properly.

This problem had been progressively worsening in the past five years. The decision to visit the clinic was prompted by the increased frequency of headaches whenever he tries to watch television at close ‘normal’ distances. He sometimes has to adjust the brightness of his phone and television screen brightness to read and watch television properly.

He denied double vision but reports blurry vision when trying to focus on nearer objects but not far objects. There is no history of excess tearing or eye discharge, eye redness, burning sensation, or itching. There are no eye medications he is using for his symptoms. His last eye exam was 10 years ago and the no significant changes.

Medications:

1. Metoprolol ER Succinate 50mg tablet, Dosage 1 tablet=50mg, Route – PO, frequency -Daily
2. Losartan/HCTZ 100/12.5mg, Dosage- 1 tablet-100/12.5mg, Route – PO, frequency-Daily
3. Aspirin 81mg chewable tablets, Dosage- 1 tablet=81mg, Route-PO, frequency-Daily
4. Metformin 500mg tablets, Dosage- 1 tablet=500mg, Frequency-Daily, Route-PO
5. Vitamin D3 5,000 IU tablet, Dosage 5000 IU – 1 Tablet, route – PO, Frequency- Daily

Allergies: VO is allergic to pollen and dust. He develops a runny rose and watery eyes whenever he is exposed to these allergens. There are no known drug allergies including penicillin and sulfur-based drugs.

Tobacco Use: VO is a known smoker with 1.1 pack-years of tobacco smoking

Alcohol and Drug Use: he is a social drinker. He drinks about two bottles of beer during weekends and social occasions.

Past Medical History:

Childhood Illnesses: he was diagnosed with presbyopia at age 10. No other significant illnesses are reported. He no history of measles, mumps, or poliomyelitis during his childhood

Adult Illnesses: he was diagnosed with hypertension and diabetes mellitus type 2 at age 47. He is not epileptic or asthmatic. There is no history of past surgeries. He reports being hospitalized once in 2012 for 3 days at the time when he was diagnosed with diabetes and hypertension. He has never been diagnosed with or treated for any mental illness. He has one sexual partner with whom he practices safe sex. The last flu shot received was seven months ago. He is seronegative for HIV/AIDS infection

Family History: VO’s father died of prostate cancer at 79, his mother died of coronavirus at 84, his paternal grandfather died of cholera at 96, and the paternal grandmother died at 91 in her sleep and the cause of her death was unknown. His elder brother, 64, suffers from presbyopia, the immediate younger brother, 48, is hypertensive, while other siblings 43 and 48 suffer from Peptic Ulcer Disease (PUD) and hypertension reactively.  He has two children, both boys 14 and 10, who both suffer from presbyopia. The genogram for family history is attached in the appendix section of this paper.

Personal and Social History: VO is married and lives with his wife and children. He enjoys photography as an occupation and during leisure. He studied photography in college for two years. He likes playing with his children after school during his free time. His activities of daily life (ADLs) majorly involve movement from place to place doing photography for his clients. He is not a staunch Christian but is religiously affiliated to the core Christian values and teachings. He never takes coffee or cocoa but prefers soya for his beverages and breakfast. His diet is mainly composed of carbohydrates with the lowest sugar, salt, and plant proteins amounts but he is not a vegan.

He loved colas and French fries in his twenties and thirties but stopped these foods in an attempt to stay ‘fit and healthy’ diet-wise He exercises regularly in the morning as directed by his primary physician but reports that his present condition has not allowed him to work out in the morning because the morning sunlight is not ‘adequate enough to allow him to see properly. He sleeps for a minimum of six hours a day and prefers sleeping early in the night. VO drives with his seat belt on and observes all traffic rules. He prefers seeing a medical doctor whenever he is sick and he does not use traditional therapies and alternative medicine.

Review of Systems:

General: no fever, weight loss of gain, weakness, or fatigue

HEENT: Head – no history of head trauma, lightheadedness, or dizziness; Ears – no ringing in the ears, ear pain, discharge, vertigo, or loss of hearing; Nose – no nasal congestion, irritation, blockage, drainage, bleeding, or stuffiness; Throat – no sore throat, no halitosis, no throat irritation, difficulty or pain during swallowing

Skin: no rashes, itchiness, color changes, dryness, scaly skin, skin moles, or nail spooning.

Neck: no pain, stiffness, lumps, or history of neck trauma

Respiratory: no cough, chest pain, shortness or difficulty in breathing, or chest tightness. The is no history of chest x-ray examination

Cardiovascular: no chest tightness, edema, palpitations, orthopnea, or paroxysmal nocturnal dyspnea

Gastrointestinal: there is no pain or difficulty in swallowing. He has no loss of appetite, nausea, or vomiting. There is no history of heartburn or change in bowel movements or habits. No history of constipation, diarrhea, bloating, or excessive burping. There is no history of melena stool, pain with defecation, or rectal bleeding. He reports no hemorrhoids. He also denies eye yellowing, abdominal pain, or hepatitis infection

Genitourinary: he reports occasional nocturia and urinary frequency. However, the is no urinary retention or incontinence. He has no hematuria or abnormal urethral discharge. He denies perineal and penile itchiness or pain. There is no dysuria, flank pain, suprapubic pain, urinary hesitancy, or urinary urgency. He has no genital ulcers or erectile dysfunction. He reports no weak urinary stream, terminal dribbling, history of UTIs. His last PSA was normal and he was informed that the DRE exam findings during the last checkup were normal; about ten years ago. He also denies a history of scrotal or groin pain or masses

Musculoskeletal: no history of joint pain, redness, stiffness, weakness, or swelling. No muscle weakness or swelling was reported. He denies a history of arthritis and lower back pains.

Psychiatric: no anxiety, depression, or suicidal ideations

Neurologic: no paralysis, numbness, tingling sensations, muscle weakness, syncope, seizures, or tremors. He denies memory or speech problems.

Hematologic: no anemia, easy bruising, nose bleeding, delayed healing, or past history of blood transfusion

Endocrine: no intolerance to heat or cold, no goiter, no excessive thirst or hunger

• OBJECTIVE DATA

PHYSICAL EXAMINATION

General: He is in good general condition, alert, and cooperates well with the examiner. He is not in any obvious respiratory distress. He has his spectacles on but appears to be straining with sight. His skin is dark in color, his eyes are brown, the hair is black.

Nutritional and Vital Signs: Weight = 230lbs, Height -5 feet 4 inches, Blood pressure reading: 125/83 mmHg, Pulse rate – 83bpm, SPO₂ saturation – 98% in room air, Respiratory rate = 22 bpm, BMI = 39.5⁰C

Pain assessment-no pain, 0/10

HEENT:

Head – no bruises, no scars, no masses;

Neurological: an examination of cranial nerves I and III – XII essentially normal

Ears: external auditory meatus is clear and clean, no wax impaction, no drainage or discharge. The tympanic membrane is non-erythematous and non-bulging. Weber’s and Rinne’s test revealed no hearing abnormalities bilaterally;

Nose: no discharge, no bleeding, no alar bruises or scars, no allergic shiners, both nares are clear and patent, there is no septal deviation or masses, no polyps or mucous plug seen, no turbinate hypertrophy, the nasal mucosa is pink

Mouth: good oral hygiene, no ulcers, no thrush or bad breath, there are no dentures or missing teeth, there is no ankyloglossia; there are moist mucosal membranes,

Throat & Neck: uvula and hard palate are seen, there is no tonsillar enlargement, there no pharyngeal erythema or tonsilloliths; pharyngeal mucosa is pink

Neck: no neck masses, no neck stiffness or rigidity, thyroid gland not palpable, no jugular venous distention, no cervical lymphadenopathy

Eye Examination:

Inspection: brown eye color, pupil size 3 mm, the pupils are equal round and reactive to light bilaterally, no nystagmus, the extraocular eye movements intact and full; the sclerae are white and anicteric. The conjunctiva is clear. The cornea is clear and the corneal reflex is intact in both eyes. There is no diplopia or orbital and periorbital edema. The eyebrows are rough, kinky, and black. The eyelashes are normally positioned, with no ptosis, fasciculations, redness, or swelling of the eyelids. The eyelids can open wide and close completely without pain or straining. The eyelids are symmetrical

Palpation: no lacrimal gland tenderness, no nodules below the eyelids,

Visual acuity:

Near vision – 20/120 OD, 20/120 OS, and therefore, 20/120 OU at a near distance

Distant vision – 20/200 OU

Ophthalmoscopic examination: there are no hemorrhages, hard exudates, or laser scars. Both discs are cream-colored and margins well defined. The arteriole-venule ratio in both eyes is 3:5 and no venous pulsations are noted in both eyes.

Chest and Lungs Examination: symmetrical chest wall moving with respirations and expands symmetrically bilaterally; the trachea is centrally placed, normal breath sounds, no rhonchi, wheezes or stridor, no egophony or tactile fremitus. No dullness or hyper resonance areas on percussion.

Cardiovascular: Regular rate and rhythms, normoactive precordium, S1, and S2 sound heard, no added sounds, normally placed apex beat.

Abdomen: abdomen is non-distended and non-tender, normoactive bowel sounds and no palpable masses, spleen, and kidneys not palpable, the liver span is 9 cm by percussion. No bruits were heard

Genitourinary: no penile or testicular lesions. No groin mases or hernias. The anal tone was normal, no rectal bleeding, prostate non-tender, the surface is smooth with midline sulcus palpated, no prostate enlargement.

Extremities: no cyanosis, edema, cyanosis, or finger clubbing. Peripheral pulses were present.

Musculoskeletal: no joint deformities, swellings, warmth, redness, or tenderness. There was no limitation in ranges of motion in all joints.

Diagnostics:

Random blood sugar: 162.1 mg/dL

Thyroid function tests ordered and results pending

1. ASSESSMENT:

VO is a 56-year-old African American who presents with a progressively worsening inability to read near writings and blurry vision for the past five years. He was diagnosed with presbyopia at age 12 and there is a positive family history of presbyopia in the first-degree relatives. He visits the clinic today because of the frequent headaches and eye strain associated with the inability to read writings at close distances and eye-straining. He is a known diabetic hypertensive on care since age 47. Physical exam reveals reduced visual acuity in near distances. His presentation and past history are consistent with functional presbyopia worsened with the advancing age.

His presbyopia is suggested by the reduction in acuity at near and normal acuity at distant examinations. There is a familial component of his presbyopia as his two sons and his brother suffer from presbyopia. His symptomatology including straining while reading blurry vision, and difficulty reading near objects highly suggest presbyopia (Ball et al., 2018). Other possible differential diagnoses for his presentation include hypermetropia, astigmatism, diabetic retinopathy, and obesity. VO is nearly morbidly obese with a BMI of 39.5.

Hypermetropia, also known as hyperopia, presents with farsightedness. The strain to read near objects causes headaches from eye-straining. However, hyperopia is common in adults but is not related to advanced age. Blurry vision is common in both hyperopia and presbyopia as seen in this patient but the blurry vision in hyperopia can occur at any distance (Cunha et al., 2018).

The patient has been diabetic for the past eight years. The quality of the management of his diabetes is not known. The possibility of diabetic retinopathy cannot be ruled despite the inconclusive retinal physical eye exam. Astigmatism is also a possibility in VO as suggested by the presence of blurry vision. A further ophthalmologic exam is required to distinguish astigmatism, diabetic retinopathy, hyperopia in this patient.

1. Plan:

Treatment: the mainstay of VO’s management would be prescription lenses. VO’s treatment would include multifocal contact lenses for his presbyopia. In addition to his glasses, he would receive these multifocal contact lenses that would adjust for any over-correction of the near distance deficits. Assessment of additional magnification power (ADD) required and refraction error would direct the selection of specific lenses (Grzybowski et al., 2020) best for this patient. Multifocal type of lenses would be advantageous over monovision lenses in that there would be a reduction in contrast sensitivity with the multifocal approach (Akella & Juthani, 2018).

Patient Education: the patient would be educated about the application and usage of the lenses. He would also be made aware of the potential adverse events that would warrant an emergency revisit to the clinic. Patient education about lifestyle modification such as weight reduction and promotion of physical exercise would help in the management of his comorbidities such as diabetes, hypertension, and obesity.  He would be advised on how to use his lenses when reading books, newspapers at close distances. This would prevent occasional headaches associated with eye-straining. Self-monitoring and management of blood sugar and blood pressure at home would be highly encouraged to avoid occult elevated blood sugar and pressures that would worsen his optic health in absence of medical care.

Health Maintenance: His health maintenance would include continued treatment of diabetes and hypertension. Measurement of the HbA1c would assess the quality of control of his blood sugars in the past 3 months. Elevated A1c would warrant adjustment of his hypoglycemic drugs. Maintenance of his blood pressure levels within the normal ranges will be important for the best response to the nonpharmacological management of presbyopia. Assessment of his diuretics as contributing factor to the worsening of his presbyopia (Fricke et al., 2018). Diuretics have been associated with the maintenance of presbyopia (Gordon Schanzlin New Vision Institute, 2017).  Family-based care is also an important aspect of VO’s care and treatment. Some of his first-degree have been diagnosed with presbyopia. Assessment of the impacts on mental health would be necessary to promote family-centered care. Evaluation of family roles would help in promoting medication adherence. The need for family counseling would be assessed

Follow-up: the patient would be seen again in two weeks to assess his adaptation to new lenses and the need for adjustments. Expected adverse events would include dizziness, nausea, and poor assessment of deaths by the patient. These adverse events usually disappear after two to three weeks of management by contact lenses.

Referral: VO would be referred to an ophthalmologist for specific eye treatment and evaluation. He would be referred to a nutritionist for dietary management, obesity control, and dietary control of elevated blood pressure.

Appendix 1: Genogram

References

• Akella, S. S., & Juthani, V. V. (2018). Extended depth of focus intraocular lenses for presbyopia. Current Opinion in Ophthalmology, 29(4), 318–322. https://doi.org/10.1097/icu.0000000000000490
• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2018). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Mosby.
• Cunha, C. C., Berezovsky, A., Furtado, J. M., Ferraz, N. N., Fernandes, A. G., Muñoz, S., Watanabe, S. S., Sacai, P. Y., Cypel, M., Mitsuhiro, M. H., Morales, P. H., Vasconcelos, G. C., Cohen, M. J., Campos, M., Cohen, J. M., Belfort, R., Jr, & Salomão, S. R. (2018). Presbyopia and ocular conditions causing near vision impairment in older adults from the Brazilian Amazon Region. American Journal of Ophthalmology, 196, 72–81. https://doi.org/10.1016/j.ajo.2018.08.012
• Fricke, T. R., Tahhan, N., Resnikoff, S., Papas, E., Burnett, A., Ho, S. M., Naduvilath, T., & Naidoo, K. S. (2018). The global prevalence of presbyopia and vision impairment from uncorrected presbyopia. Ophthalmology, 125(10), 1492–1499. https://doi.org/10.1016/j.ophtha.2018.04.013
• Gordon Schanzlin New Vision Institute. (2017, June 9). Presbyopia. Gwsvision.Com. https://www.gwsvision.com/aging-vision/presbyopia/
• Grzybowski, A., Markeviciute, A., & Zemaitiene, R. (2020). A review of pharmacological presbyopia treatment. Asia-Pacific Journal of Ophthalmology (Philadelphia, Pa.), 9(3), 226–233. https://doi.org/10.1097/APO.0000000000000297