A Brief Note On Pain, Hypertension, Gout, And Diabetes Mellitus ( Dm ) Evaluation
1448 WordsJan 15, 20176 Pages
Subjective Data:
Chief Complaint: Right ankle pain for two days, routine visit for osteoarthritis, hypertension, gout, and diabetes mellitus (DM) evaluation. History of present illness: Mrs. V. J. a 68 year-old-African American female presented in the clinic complaining of a burning pain, stiffness, swelling right ankle, which radiates to the right metatarsophalangeal joint for two days, pain scale seven out of ten. She denied falling or hitting her right ankle against an object, just woke up around three that morning to use the bathroom and could barely walk. She also stated that right ankle edema has increased more in the past two days due to cold weather. She takes Norco 10/325mg two tablets orally every six hours and apply warm…show more content… She had three siblings, one sister and twin brothers, sister is 60 years old, newly diagnosed with DM and twin brothers are 58 years old alive and well.
Review of System (ROS)
General: Neat
Skin: Reports swelling right ankle and right big toe pain.
Eyes: She wears reading glasses
Ears: Denies ringing in the ear, pain, discharge, or hearing impairment.
Nose: Denies nasal discharge, Congestion, or problems with smell.
Throat: Denies problems with her gum and mouth. Swallows without any difficulty.
Neck: Denies any edema or bruises around the neck.
Respiration: Denies labored breathing.
Cardiovascular: Denies chest pain, bilateral ankle edema, but severely increased on the right with burning pain.
Gastrointestinal: Denies anorexia, nausea and vomiting, heartburn, abdominal pain, or constipation.
Endocrine: History of Type two DM
Objective Data:
Vital signs: Temperature 98.7 Fahrenheit, Blood pressure 128/82, Respiration 16, weight194, height 5feet 8 inches, body mass index (BMI) 28.
Generalized appearance well-kept wore a decent outfit, overweight, ambulates with a walker.
Skin: Warm to touch, dry and intact
Head: Normocephalic, atraumatic.
Ear: No discharge or cerumen noted bilaterally, tympanic membrane normal without redness or edema.
Nose: Nares patent without any obstruction. No frontal or maxillary tenderness during palpation of the sinus cavities.
Pharynx: Oral mucosa moist, no dental cavities or plague