Download History and Physical

History and Physical Examination
Chief Complaint: abdominal pain
History of Present Illness: Mr. John Smith is a 47 year old Caucasian male who approximately 2 weeks
ago developed the gradual onset of steady, burning, epigastric abdominal pain with radiation to the midback. The symptoms are persistent and have worsened. Additionally, he admits to a fever, nausea,
vomiting, flatulence and abdominal distention. The symptoms have been exacerbated by fatty foods,
spicy foods, alcohol, tomato products and lying on his back. He has been taking Mylanta and ranitidine
and feels that the symptoms are unchanged. The patient has been seen previously by Raymond Jones,
MD, at which time studies were performed but he is unable to provide any details. No diagnosis was
made. He was seen in the Sutter Roseville Medical Center emergency room, where tests were obtained,
which included: a CBC, a Chemistry Panel, an Amylase, a Lipase, a Chest Xray and a CT Scan. The
diagnosis of possible pancreatitis was rendered.
Review of Systems:
General: He admits to fever, chills, malaise and fatigability but denies night sweats, recent weight
gain, recent weight loss, or a history of familial disorders.
Head: He denies chronic or recurrent headaches, migraine headaches, a history of major head
trauma, recurrent vertigo, recurrent syncope or seizures.
Eyes: He denies recent loss of vision, recent inflammation or infection, pain, photophobia, diplopia,
visual field loss, a history of color blindness, major eye trauma, glaucoma or cataracts.
Ears: He denies loss of hearing or deafness, ear pain, tinnitus, vertigo, auditory canal discharge,
recurrent otitis media or mastoiditis.
Nose: He admits to a nasal obstruction but denies frequent coryza, recurrent or chronic rhinitis,
chronic sinusitis or epistaxis.
Mouth: He denies soreness of the mouth, soreness of the tongue or bleeding gums.
Throat: He admits to hoarseness and frequent or recurrent sore throats but denies recurrent
tonsillitis, a recent voice change or a history of oropharyngpeal carcinoma.
Neck: He denies swelling, pain, lymph node enlargement, goiter, stiffness, limitation of motion, a
history of a thyroglossal duct cyst or a history of a branchial cleft cyst.
Respiratory System: He denies chest pain, shortness of breath, wheezing, dyspnea, proxysmal
nocturnal dyspnea, orthopnea, chronic cough, abnormal sputum production, hemoptysis, purulent
sputum, night sweats, cyanosis, asthma, emphysema, pleurisy, bronchitis, pneumonia or tuberculosis.
Cardiovascular System: He denies palpitation, tachycardia, arrhythmias, chest pain, heart murmurs,
exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, hypertension, cough, cyanosis,
changes in skin color, ascites, edema, intermittent claudication, cold extremities, angina, myocardial
infarction, congestive heart failure, a history of phlebitis, deep venous thromboses, congenital cardiac
anomalies or rheumatic fever.
Breasts (Male): He denies gynecomastia, trauma, masses, pain, changes in nipples, nipple discharge
or recent nipple inversion.
Gastrointestinal System: He admits to a change in appetite, fever, nausea, vomiting, flatulence,
abdominal pain, abdominal distention and fatty food intolerance, but denies wheat intolerance,
lactose intolerance, weight changes, dysphagia, hematemesis, eructations, abdominal masses,
abdominal hernias, groin hernias, jaundice, change in color of urine, change in color of stool, change
in frequency of stool, change in the consistency of stool, hematochezia, melena, acholic stools,
diarrhea, constipation, hemorrhoids, ascites, a history of ulcers, gallbladder disease, liver disease,
hepatitis, pancreatitis or tumors of the stomach or intestine.
Genitourinary System: He denies change in color of urine, dysuria, hesitancy, frequency, urgency,
polyuria, oliguria, nocturia, hematuria, pyuria, urinary retention, urinary straining, incontinence, renal
pain or colic, passage of stones or gravel or hernias.
Male Venereal Disease Symptoms: He denies the presence of a chancre, an ulcer, a bubo, an
inguinal or perineal sinus or fistula, genital warts, genital vesicles, dysuria, anal pain, anal bleeding or
penile or anal discharge.
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Venereal Disease History: He denies any history of sexually transmitted diseases.
Central Nervous System: He denies syncope, periods of loss of consciousness (momentary or
prolonged), seizures, tremors, memory loss, generalized weakness or a history of a cerebrovascular
accident.
Cranial Nerves: He denies disturbances of smell (CN I), visual disturbances (CN II, III, IV, VI),
orofacial paresthesias and difficulty chewing (CN V), facial weakness and taste disturbances (CN VII),
disturbances in hearing and equilibrium (CN VIII), difficulty with speech, swallowing and/or taste (CN
IX, X, XII), neck motion limitation (CN XI) or unilateral trapezius weakness, paralysis and/or atrophy
(CN XI). Motor System: He denies weakness, atrophy, involuntary movements, altered gait,
incoordination, paralyses or peripheral neuropathy.
Sensory System: He denies acute pain, chronic pain, lightning pain, girdle or radicular pain,
paresthesia, hyperesthesia, hypesthesia, anesthesia or dysesthesia.
Autonomic System: He denies urinary incontinence, fecal incontinence, excessive sweating,
erythema, cyanosis, pallor or extreme heat and/or cold sensitivity.
Musculoskeletal: He denies muscle or joint pain, migratory distribution of pain, limitation of motion,
stiffness, swelling or edema, erythema, rubor, muscular weakness, wasting, atrophy, night cramps,
fractures, dislocations, sprains, bone deformities, a history of myositis, a history of arthritis, a history of
gout, a history of a primary tumor of bone or a history of tuberculosis of bone or joints.
Endocrine System: He denies changes in skin pigmentation, weakness, goiter, exophthalmos,
dryness of skin and hair, intolerance to heat or cold, tremor, polyphagia, polydipsia, polyuria,
impotence, sterility, changes in glove, shoe, or hat size, a history of diabetes or a familial history of
multiple endocrine neoplasia.
Hematopoietic System: He denies anemia, spontaneous bruising or bleeding, a history of
thromboses, a history of thrombophlebits, a history of prior transfusions, a history of leukemia or
lymphoma, a congenital blood dyscrasia, an acquired blood dyscrasia or a history of non-medical
radiation exposure.
Lymph Nodes: He denies lymph node enlargement, pain or suppurative drainage.
Integument: He denies color changes, changes in pigmentation, skin temperature changes,
eruptions, pruritus, susceptibility to bruising or susceptibility to bleeding.
Allergies: The patient denies medication allergies.
He denies an allergy to iodine. He denies an allergy to shellfish. He denies an allergy to tape. He denies
an allergy to latex.
Past Medical History:
Surgical History: Tonsillectomy: He had a tonsillectomy in June 1965. He experienced no intraoperative events and no post-operative complications. The surgery was a success.
Trauma History: He was injured in February 1992 in a vehicle accident. The course of treatment was
successful.
Diseases: Hypertension: He was given the diagnosis of hypertension in May 2000 and medication
was prescribed. Routine tests are to be performed. He has seen a specialist who recommended that
the medication be continued. The current medication regimen is: Lotensin. The disease is well
controlled with the medication. Type II Diabetes mellitus: He was diagnosed with type II diabetes
mellitus in November 2003 and medication was prescribed. Routine tests are performed. He has
seen a specialist who recommended that the medication be continued. The current medication
regimen is: Glucophage. The disease is well controlled with the medication.
Social History:
Demographics: The patient is married with 2 living children. Alcohol Use: He admits to drinking
once or twice a week but never becomes intoxicated. Illegal Drug Abuse: He denies ever using an
illegal drug. Prescription Medication Abuse: He denies addiction to a prescribed medication.
Tobacco Use: He denies ever using tobacco. Domestic Violence: He denies being a victim of
domestic violence.
Family Medical History:
Gallbladder Disease: father, paternal grandmother. Breast Cancer: mother.
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Medications:
Lotensin 10 mg QD for hypertension. He has been taking this medication since May 2000. The
dosage has not been changed. The illness is well controlled with the medication.
Glucophage 1000 mg BID for Type II Diabetes mellitus. He has been taking this medication since
November 2003. The dosage has not been changed. The illness is well controlled with the
medication.
Physical Examination:
Blood Pressure: 142/82
Pulse: 68
Respiration: 16
Temperature: 98.7
Height: 5’ 10”
Weight: 186#
The patient is a well-developed, well-nourished, Caucasian male, alert, cooperative, able to relate an
adequate history, in no apparent distress.
Head: Normocephalic without deformities. The temporal arteries are normally pulsatile. There are no
masses or other lesions.
Eyes: The pupils are equally round and reactive to light and accommodation. The lids, conjunctivae
and sclerae are unremarkable. Extraoccular motions are normal. There is no nystagmus.
Funduscopic and visual field examinations appear to be without defects. Visual acuity appears to be
grossly normal.
Ears: The ears evidence no deformities or lesions. There is no discharge. There is no discharge.
Hearing appears to be grossly normal. Hearing is normal per Rinne's and Webber's tests.
Nose: The nasal mucosa, septum and turbinates are normal. There is no discharge. No masses or
other lesions are evident.
Mouth and Throat: The lips, teeth, gums, tongue, mucosa, palates and uvula are normal. The tongue
protrudes in the midline. The tonsils are unremarkable. The gag reflex is intact. There are no
apparent masses or other lesions.
Neck: The trachea is midline. There appears to be normal range of motion. The carotid pulsations
are full and equal bilaterally and no bruits are noted on auscultation. There is no jugular venous
distention. The thyroid is normal and symmetrical without masses. There is no apparent
lymphadenopathy. No masses or other lesions are appreciated.
Chest and Lungs: The chest is symmetrical and moves equally with respiration. Expansion is
normal. There is no tactile fremitus or crepitus. Percussion reveals no pathology. The lungs appear
clear to auscultation without wheezes, crackles, rhonchi or rubs.
Heart: The heart is regular in rate and rhythm. The PMI is in the left fifth interspace. There are no lifts
or thrills. S1 and S2 are normal to auscultation. Splits, gallops, rubs, murmurs and snaps are absent.
Breasts: The breasts are symmetrical. The areolae and nipples are normal. There is no discharge.
There are no dominant masses or stigmata of malignancy. The axillae are unremarkable.
Supraclavicular and infraclavicular lymphadenopathy is absent.
Abdomen: The abdomen is of unremarkable contour and symmetry. Tenderness was noted to
deep palpation in the epigastrium and left upper quadrant. There are no obvious masses. Organ
enlargement is not evident. Bowel sounds are normally active. There are no bruits. There are no
apparent hernias. There is no inguinal lymphadenophy. Femoral pulsations are normal and equal
bilaterally. Costovertebral angle tenderness is absent.
Male Genitalia: The penis, scrotum and testicles are without apparent pathology. There is no
epididymal tenderness. Urethral discharge is absent. No masses or other lesions are noted. There
are no obvious inguinal or femoral hernias. Inguinal lymphadenopathy is absent.
Male Anus/Rectum/Prostate: The perineum and anus evidence no masses or other lesions. There
are no obvious fissures or fistulae. Sphincter tone appears adequate. The rectal walls are
unremarkable without palpable masses or other lesions. The prostate is of normal size and
consistency without palpable masses. Anoscopy reveals no significant pathology. Flexible
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sigmoidoscopy to 60 centimeters identifies normal mucosa without evident lesions. Stool for occult
blood is negative.
Musculoskeletal: There appears to be normal posture, alignment and symmetry. Abnormal joint
heat, swelling, discoloration or tenderness are not apparent. Muscle tone, strength and range of
motion are unremarkable.
Neurologic: The sense of smell appears to be unaffected (CN I). Visual acuity, visual fields and
funduscopy are normal (CN II). Eyelid opening and pupillary constriction are unremarkable.
Extraoccular motions, other than medial-caudal and lateral, are unrestricted (CN III). Medial-caudal
extraoccular motion is unrestricted (CN IV). The corneal reflex, facial sensation, mandibular motion
and bite strength appear to be normal (CN V). Lateral extraoccular motion is unrestricted (CN VI). The
eyebrows raise and the eyelids close symmetrically (CN VII). There is no evidence of facial muscle
weakness (CN VII). The sense of taste appears to be unaffected (CN VII). Hearing appears to be
within normal limits (CN VIII). Rinne's and Weber's tests are unremarkable (CN VIII). There are no
abnormalities of gag reflex, palate elevation or phonation (CN IX & X). Lateral head rotation, neck
flexion and shoulder shrug are normal (CN XI). The tongue protrudes in the midline (CN XII). Tongue
lateral deviation strength appears to be normal (CN XII). Rapid alternating movements and finger to
nose tests are normal. Motor strength, sensation and vibratory sensation appear to be unaffected.
Romberg's sign is negative. The gait is within normal limits. Deep tendon reflexes are average (2+).
Impressions:
1. [789.00] Abdominal Pain
2. [401.1] Hypertension
3. [250.00] Type II Diabetes Mellitus
Recommendations: The recommendations are to be entered by the examining physician following the
completion of the formal patient interview. The following is an example written by our medical consultant
Rolf Gulbrandson, MD:
With worsening of his symptoms, the patient will be admitted to the hospital. He will be made
NPO and IV hydration will be instituted. His previous studies, including the CBC, Chemistry
Panel, Amylase, Lipase, Chest Xray, and CT Scan will be obtained and reviewed. The CBC,
Chemistry Panel, Amylase and Lipase will be repeated. A repeat CT Scan will be requested if
indicated. Antibiotic coverage is being withheld pending the results of the previously performed
and currently requested tests. A consultation by Dr. Jones of Gastroenterology is pending. The
patient and his family have been informed regarding his diagnosis, prognosis and treatment plan.