Subjective Information And History Patients Chart Essay

PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

Scenario: Mr. B, a 67-year-old-man, came to the ER complaining of severe pain to his left hip and leg after falling over his dog at home. Left leg appears shortened with swelling in his calf, bruised, and limited range of motion.Mr. B has a history of impaired glucose tolerance and prostate cancer. Home medications include atorvastatin and oxycodone for chronic back pain. Mr. B’s labs, taken during a previous visit with his primary care doctor, revealed elevated cholesterol and lipids.

A (assessment): Ms. O’Reilly’s vital signs are temperature of 37.5 C, pulse of 112, blood pressure of 102/52, and respirations of 24. Her respirations are still deep but have a regular rhythm. She has a CBS of 8.1 and regular insulin running as per orders. The lab work shows uncompensated metabolic acidosis with no hypoxia. Ms. O’Reilly’s neurological status has improved with a GSC of 13. Her dehydration is being treated with NS containing 40mEQ KCL/L running at 200ml/hr and potassium levels maintained at 4.

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

The patient has no family history of heart disease or diabetes, however both her parents are on medication for high blood pressure. Her paternal grandmother died of breast cancer at age 47. Her maternal grandmother

PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia noted. No edema noted in extremities. Patient skin is cool to touch, slightly clammy. EEG shows prolonged QRS wave, with ischemic ST changes and PVCs. Chest radiograph clear.

PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia

General Health State (present weight – gain or loss, reason for gain or loss, amount of time for gain or loss; fatigue, malaise, weakness, sweats, night sweats, chills ): She currently weighs 110lbs. No weight loss. She is well developed and nourished. No distress. States she has always been healthy, other than occasional constipation.

The Consultation Report dated 12/07/2016, indicated that the claimant presented with uncontrolled type 2 diabetes mellitus. He also had a chronic back pain, arthritis, and a history of diabetic neuropathy. His blood sugar was 800 (critical stage). His blood pressure was 129/62 mmHg. The physical examination revealed mild thyromegaly, a decreased air entry at the base of the lungs, and a decreased peripheral palpable pulse. The exam also revealed loss of hair and chronic ischemic changes. Toe deformity and peripheral deformity were noted. He was on Levemir and Novolog. According to the provider, the claimant was on steroids, which has caused an increased blood sugar level. HBA1c

My patient is a 58-year-old female, who presents with controlled type II diabetes, hypertension, and possibly thyroid tumors that have been there for a few years. She is under the care of a physician for her diabetes and associated controlled hypertension. I recommended several times that she see her physician after feeling the tumors around her neck and thyroid. Her medical history also indicates that she had rheumatic fever twelve to thirteen years ago, has arthritis in her knees, and occasional headaches. She is 5”3 and weighs 216 pounds. Her blood pressure was 126/80, pulse was 88 BPM, respirations were 20, and her temperature was 98.2 Fahrenheit. She doesn’t smoke and I made sure that she had eaten lunch and wasn’t hungry. She is currently on 100 mg Metformin for her diabetes, 120 mg. Lisinopril for hypertension, 40 mg. of Lovastatin to lower cholesterol, 80 mg. of Aspirin to prevent cardiovascular disease, and daily insulin. Reviewing her medical HX, I was informed that she usually checks her blood glucose daily, but had recently run out of strips, so it had been a

The general health of the patient is currently being compromised due to present illness mentioned above, but is stable. L.H. reports his usual health to be, “normal and not too crazy like this”. Patient has some fatigue noted while conducting daily activities; No recent weight change, fever or sweat. The skin noted to some discoloration on upper right side of back. There is no pruritus, rash or lesions present. Bruises noted bilateral on arms. Patient reported taking baby aspirin as daily medication. His hair is greying and thinning with no hair loss.

On Exam:  BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the

She reports a history of back pain, ovarian cysts excision, and breast tumor. She denies chest pain, shortness of breath, or palpitations. Patient reports that her immunizations and preventive care are up to

Healthcare maintenance. The patient has not had a physical in years. We will set her up to come back for this at next appointment. She is not had cholesterol done for quite some time. She does continue on TriCor for her hypertriglyceridemia. We will plan on doing blood work to include a vitamin D, CMP, magnesium, lipid panel, hemoglobin A1c, prior to her appointment in three months. She is seeing Christine Wasilewski, MD for her B12 deficiency and anemia. I will not therefore order test for