Comprehensive Adult Health History and Physical Examination Sample

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Comprehensive Adult Health History and Physical Examination Sample

PATIENT INFORMATION

Name: Mr. V.O

Date of Birth: 5/5/1965

Age: 46

Ethnicity: African American (Nigerian)

Gender: Male

Source: Patient

Date of Assessment: 4/1/2021

Occupation: Photographer

Allergies: Allergic to pollens and house dust mites. The allergens make him have a runny nose and watery eyes

Current 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, Dosage5000 IU – 1 Tablet, route – PO, Frequency- Daily

PMH:

Childhood Illnesses: Presbyopia diagnosed at 10 years of age.

Allergic rhinitis since childhood

Adult Illnesses: Diabetes diagnosed in 2012

-Hypertension diagnosed in 2012

-There is a history of past hospitalization due to hyperosmolar non-ketotic coma. No previous blood transfusion. No history of TB or HIV. No previous history of surgical procedures.

Immunizations: All up to date. Last tetanus vaccine given on 10th 7/2020

Personal/social History: Studied photography for 2-years at a college level (Associate in Arts degree), He smokes and he is a social drinker.

Family History: His grandpa is John Onuchukwu, who succumbed to Cholera at the age of 96yrs (1871-1967). The grandmother, Elizabeth onuchukwu, died at 91(1886-1977). The cause of death was not determined as she died in sleep. His dad, Benjamin Onuchukwu, died at age 79 (1930-2009) of prostate cancer while the mother, Theresa Onuchukwu died at age 84(1936-2020) of corona virus. He has four other siblings: Josephat Onuchukwu born in 1957, 64 years old today, alive and suffering from presbyopia; Uche Onuchukwu born in1978, 43yrs old today suffers from ulcer; Mark onuchukwu born in 1973, 48yrs old today and has high blood pressure and Chimezie Onuchukwu (1976), 45 years old, suffers from high blood pressure.

He has 2-children 1. Oluebube Onuchukwu born in 2007, aged 14 today, suffers from presbyopia 2. David Onuchukwu born in 2011, aged 10 today, suffers from presbyopia

Nutritional History: three major meals per day with frequent snacks in between.

Subjective Data:

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

Symptom analysis/HPI:

The client is a known presbyopic patient. He has been using eye glasses since childhood but for the past three months, complaints of inability to read with or without the glasses. He reports that he cannot read clearly prints that are at a close distance to him; he has to move the reading materials away from the eyes. Further, he has a problem reading smaller prints; he therefore uses larger fonts for his phone. He requires a bright light to read and is unable to see in a dim room. Sometimes he strains a lot until the eyes aches. He reports frequent headaches. He also reports squinting quite often. As a photographer, his eyes are the most important organs; therefore, the condition has adversely affected his job and a cause of his current financial strains since he is the breadwinner.

He also reports associated dyspnea only on exertion. He had one episode of chest pain in the past three months. He reports he has had problems achieving a weight loss since childhood. Due to his job, he travels quite often and eats a lot of junk food at different restaurants. He also reports to eat three meals per day with snacks and sweetened drinks in between the main meals. Moreover, he could occasionally miss medications while he travelled. He is a known diabetic and hypertensive patient since 2012.

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever, fatigue. Reports added weight.

NEUROLOGIC: Reports headaches. Denies loss of consciousness

HEENT: Head: Denies head injury. Eyes: Reports blurred vision and pain. He uses glasses. He reports watery eyes on exposure to pollen and house dust mites. Ears: Denies pain, discharge, loss of hearing, tinnitus, and vertigo. No previous ear infections. Nose: reports runny nose on exposure to pollen and house dust mites. He denies congestion, stuffiness, itching, bleeds or sinus tenderness. Throat: Denies sore throat, voice changes and halitosis.

RESPIRATORY: Reports exertional dyspnea. He denies cough, sputum production and hemoptysis.

CARDIOVASCULAR: He is hypertensive. He denies palpitations, orthopnea, limb edema, paroxysmal nocturnal dyspnea.

GASTROINTESTINAL: Denies nausea and vomiting. Denies abdominal pain, diarrhea, constipation, flatulence and any bowel changes

GENITOURINARY: Denies urgency, frequency, nocturia, dysuria, burning sensation, flank pains and hematuria. Denies previous or current urinary tract infections

MUSCULOSKELETAL: Denies joint pain or stiffness.

SKIN: Denies rushes, hypo/hyper pigmentations, pruritus or skin infections.

Objective Data:

General appearance: An African American male adult in a fair general condition. He walks into the examination room in a normal gait. He is obviously obese. He is relaxed, calm and well composed. He is well kempt and groomed with nicely coiffed hair and with a nice fragrance. He is friendly, and overfamiliar with the environment. He is in a conscious mind. He has a clear and a coherent speech.

He is not in an obvious respiratory distress. He is not pale or jaundiced. No edema, cyanosis, lymphadenopathies. He is well hydrated

Measurement:

Weight=230lbs; Height- 5 feet 4 inches; BMI-39.5 kg/m2;

Vital signs: BP-125/83 mmHg; HR-83 beats/minute; RR- breaths/minute; SPO2-98%; Pain score-0

Skin: He has a dark complexion and black hair. The skin is moist and warm. The skin has a smooth and with normal turgidity. The fingernails are pink in color, oval shaped, and have no pathologic lesions. The toe nails are pink in color, round shaped without pathologic lesions. No primary or secondary skin lesions.

Head & Face: The head is normocephalic with no lacerations, deformities or asymmetry. The hair dark and well distributed throughout the scalp. The scalp is dry with no lesions, infective or inflammatory.

The face is oval shaped. Facial movements are symmetric. No drooping of eyelids, no involuntary facial movements.

Right eye: Present. Primary position, looking straight ahead and the visual axis is parallel to the head’s sagittal plane. Allergic shiners present. Visual acuity is less than 6/12. The eye lids’ opening is symmetrical. There are no lumps, scales, discharge, pus or mucus around the eyelids margins. The conjunctiva is white. The cornea is clear, and has a lustrous surface. The iris is flat and brownish in color with a centrally located pupil. The pupil is round, 3mm in diameter in a bright lit room and constrict to direct light (illumination). The lens is transparent with increased curvature. Extra ocular muscles are intact. On ophthalmoscopy, red reflexes are normal, there is mild macular edema with dot and blot hemorrhage.

Left eye: Present. Primary position, looking straight ahead and the visual axis is parallel to the head’s sagittal plane. Allergic shiners present. Visual acuity is 6/12. The eye lids’ opening is symmetrical. There are no lumps, scales, discharge, pus or mucus around the eyelids margins. The conjunctiva is white. The cornea is clear, and has a lustrous surface. The iris is flat and brownish in color with a centrally located pupil. The pupil is round, 3mm in diameter in a bright lit room and constrict to direct light (illumination). The lens is transparent with increased curvature. Extra ocular muscles are intact. On ophthalmoscopy, red reflexes are normal. Macular edema is not as marked as on the right side. Dot and blot hemorrhage present.

Ear: Both ears are present on either sides of the face. The auricles are symmetric. On otoscopy, the external auditory meatus are clear without wax impaction. The tympanic membrane are translucent and pale gray in color with a cone of light at the 5 o’clock position.

Tuning fork tests:

-Weber’s test is central

Rhine’s test-air conduction is greater than bone conduction. Normal results

Nose: Normal external nasal anatomy with bilateral symmetrical nares. A transverse nasal crease is present. Using a speculum, the mucosa is moist and pink in color. Normal septum; no deviation, perforations, tumors or ulcers. Turbinates are boggy and pale blue in color. Maxillary sinuses are non-tender

Mouth & Throat: the lips are symmetrical and pink in color. Oral mucosa is moist and pink in color; no ulcerations, erythema or other lesions. The gums are pink in color, no bleeds, not swollen, no odor, no ulcerations. 32-teeth, whitish in color; 2 maxillary incisors are yellow; no dentures or prosthesis. Tongue is pink, central, rough dorsal surface, no ulcers, hairs or furrows, smooth ventral surface, comfortably fits the oral cavity. Palate is pink with a ridged hard palate. Pharynx: Tonsils are present, no enlargement, or exudates. Uvula present and upwardly movable.

Neck: No cervical lymphadenopathies. Trachea centrally located. No palpable central neck mass

Back: Inspection: No deformity, no skin lesions, no surgical scars, no masses. Palpation: No tenderness over the spine and muscles. Shoulder symmetrical

Posterior Thorax & Lungs: inspection: No masses, moves with respiration. Palpation: bilateral symmetrical, normal tactile fremitus, no tenderness or masses. Percussion: Normal resonance. Auscultation: Bilateral equal air entry, bilateral vesicular breath sounds heard. vocal fremitus normal

Breasts, Axillae, and Epitrochlear Nodes: Being male, no significant findings. Absent axilla and epitrocheal nodes

Upper Extremities: Hands: no color discoloration, no masses/swelling, no deformity, warm temperature, no tenderness, wrist, metacarpo-phalangeal and inter-phalangeal joints exhibit full range of motions. Arm: No color discoloration, no masses, no deformity, warm temperature, elbow joint full flexion and extension. Shoulder joints symmetrical, shoulder joint full range of motions. Full neck flexion, extension, rotation and cervical side-bending. Bulk, tone, reflexes are normal. Muscle power of 5/5 in both upper limbs. Radial and brachial pulse present, symmetrical, regular, and of good volume.

Anterior Thorax: Inspection: symmetrical, moves with respiration, no skin lesions, no masses. Palpation: No masses, no tenderness, bilateral equal chest expansion, tactile fremitus normal. Percussion: Normal resonance. Auscultation: Bilateral equal air entry, bilateral vesicular breath sounds heard. Vocal fremitus normal

Cardiovascular: Normal jugular venous pressure. Carotid pulse is present, regular, strong, good volume, no bruits. The precordium is normal and not hyperactive. Point of maximum impulse is at 5th intercostal space, an in mid-clavicular line. S1 and S2 are heard, no thrills, murmurs or any other added sounds.

Abdomen: Inspection: Marked abdominal distension with central obesity. No dilated veins, no surgical scars, no therapeutic marks, moves with respiration. On light palpation, no tenderness is elicited, no masses, no organomegally. On deep palpation, no tenderness elicited, no masses, no organomegally. No tenderness over the costovertebral angles. Liver and spleen not enlarged. Percussion: Tympanic. Auscultation: Bowel sounds heard

Lowe Extremities: femoral, popliteal, dorsalis pedis and posterior tibial pulses are present, regular, strong and of good volume bilaterally. No palpable inguinal lymphadenopathy. No discoloration or ulcerations of the lower extremities. No lower limb edema. Hip joint, knee joint, ankle joint, metatarsophalangeal and inter-phalangeal joints are flexible, and exhibit full range of motions specific for the particular joint. There is normal muscle bulk, tone and reflexes. Muscle power 5/5 bilateral lower limbs. No varicose veins. The right and left legs are neutrally aligned (no varus or valgus deformities). External genitalia is normal, no hernia findings. Negative Romberg’s test

Nervous System: GGCS-15/15. Patient is oriented in time, person and place. CN I, II, III, IV, VI are intact. CN VI, VIII, IX, X are normal. There is normal sensation to pain, light touch and vibration. Normal muscle bulk, tone, and reflexes. Muscle power 5/5 in both limbs.

Active Problems

  1. Diabetes-the patient was diagnosed of diabetes in 2012. He is obese, a risk factor for diabetes (ADA, 2019). Further, the patient is an active smoker and an occasional drinker. Smoking and alcohol are modifiable risk factor for diabetes mellitus (ADA, 2019). Moreover, the patient is an African American, an ethnic community with higher risks for diabetes mellitus (Sapra & Bhandari, 2020). Diabetes mellitus causes chronic micro vascular complications such as retinopathy. Patients with retinopathy presents with blurred vision and a progressive and an insidious visual acuity loss (Shukla & Tripathy, 2021). Therefore, diabetic retinopathy is a differential diagnosis in the case described. The findings in the patient including a low visual acuity, macular edema and dot and blot hemorrhages could underpin the diagnosis.
  2. Hypertension-the patient has been hypertensive since 2012. Long durations of hypertension predispose an individual to complications such as retinopathies and cardiovascular events. The patient reports a one episode of chest pain in the past three months. Prescription of Aspirin, as evidenced in the medication list is an intervention to prevent the cardiovascular events such as myocardial infarction or coronary artery disease (Zanchetti, 2017). Retinal complications include hypertensive retinopathy, a possible differential diagnosis in the patient.
  3. Allergic rhinitis: on exposure to allergens, the condition is characterized by watery eyes, itchy nose, sneezing and nasal obstruction (Akhouri & House, 2021). The patient is allergic to pollen and house dust mites which are perennial allergens. She reports to have runny nose and watery eyes on exposure to the allergens. The diagnosis is underpinned by the physical examination findings which reveal a boggy and pale blue turbinates. Further, the patient has allergic shiners and a transverse nasal crease which are ocular and nasal signs respectively of allergic rhinitis (Akhouri & House, 2021).
  4. Presbyopia: Age related condition characterized by a loss in the flexibility of the lens. In children, it occurs as farsightedness. Characteristic features include inability to read prints closer to the eye, moving reading materials far away from the eyes, straining, headaches, and squinting (Singh & Tripathy, 2020). Visual acuity is decreased on physical examination. The patient present with the typical features; however, his case could be superimposed with diabetic and hypertensive retinopathy.

Risk Profile

  1. Obesity
  2. Physical inactivity

References

 
1871-1967
1886-1977
Grandfather: John

Died: 96yrs

From cholera
Grandmother: Elizabeth

Died: 91yrs

Died while sleeping

Cause: Unknown
1869-1959
Grandpa: James

Died: 90

Cardiac arrest
1880-1966
Grandma: Hannah

Died: 86

Stroke
1930-2009
Dad: Benjamin

Died: 79

Prostate Cancer

 
1936-2020
Mother: Theresa

Died: 84

COVID-19
Valentine: Patient
14
Presbyopia
10
Presbyopia
1965 to date

Age: 46yrs

DM; HTN; Obesity; Allergic rhinitis; Presbyopia
64
Brother: Josephat

Presbyopia
1957 to date
48
1973 to date
45
1976 to date
Brother: Chimezie

HTN
43
1978 to date

Brother: Uche

Gastric Ulcers

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