CASE STUDY 3
nikkyvu
ROS_Template.docx-General Usual weight, recent weight change, weakness, fatigue, or fever
-Skin Rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in size or color moles
-Head, Eyes, Ears, Nose, Throat (HEENT):
- Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, Tinnitus, Vertigo, earaches, infection, discharge, If hearing is decreased, use or nonuse of hearing aids, Nose and Sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nose- bleeds, sinus trouble. Throat ( or mouth and Pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, sore tongue, dry mouth, frequent sore throats, hoarseness.
-Neck “Swollen Glands,” goiter, lumps, pain, or stiffness in the neck.
-Breast Lumps, pain, or discomfort, nipple discharge
-Respiratory Cough, sputum (color quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (Pleuritic pain).
-Cardiovascular “Heart trouble”; high blood pressure; rheumatic fever; heath murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema).
-Gastrointestinal Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change bowel habits, pain constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble.
-Peripheral Vascular Intermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; past clots in the veins; selling in claves, legs, or feet; color change in fingertips or toes during cold weather; selling with redness or tenderness.
-Urinary Frequency or urination, polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.
-Genital
Male: Hernia, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infection and their treatments. Sexual interest (Libido), function, satisfaction
Female: Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, any problems, including pain during intercourse (dyspareunia)
-Musculoskeletal Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.
-Psychiatric Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts.
-Neurologic Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” tremors or other involuntary movement seizures.
-Hematologic Anemia, easy bruising, or bleeding
-Endocrine Heat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).
-Physical Examination
General Survey: MN is a short, overweight middle-aged female, who is animated and responds quickly to questions. Her hair was well groomed. Her color is good, and she lies flat.
Vital Signs: Ht(without shoes) 157 cm (5’2”). Wt (dressed) 65 kg (143 lbs) . BMI 26, BP 164/98 right arm supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6F.
Skin: Palms cold and moist, but color good. Scattered Cherry angiomas over upper trunk. Nails without clubbing , cyanosis.
Head, Eyes, Ears, Nose, Throat (HEENT): Head; hair of average texture, Scalp without lesions, normocephalic/ atraumatic (NC?AT). Eyes; Vision 20/30 in each eye.
Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking. Ears: Cerumen partially obscures right tympanic membrane (™); Left canal clear, ™ with good cone of light. Acuity is a good to whispered voice. Weber midline. AC>BC. Nose Mucosa pink, septum midline. No sinus tenderness. Mouth: Oral mucosa pink. Dentition is good. Tongue midline. Tonsils absent. Pharynx without exudates.
Neck: Neck Supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.
Lymph Nodes: No cervical, axillary, or epitrochlear nodes.
Thorax and Lungs: Thorax Symmetric with good excursion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Cardiovascular: Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1,,.S2,: no S3 or S3,. A II/VI medium-pitched midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No diastolic murmurs.
Breast: pendulous, symmetric.. No masses; nipples without discharge.
Abdomen: Protuberant. Well-healed scar, right lower quadrant. Bowel sounds active. No tenderness or masses. Liver span 7cm in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen not felt. No costovertebral angles tenderness (CVAT).
Genitalia:
Female External genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact.
Male External genitalia without discharge or lesions. No scrotal or testicular mases or swelling, no hernia.
Rectal: No external hemorrhoids, tight sphincter tone, rectal vault without masses, stool brown negative for occult blood.
Extremities: Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan's sign.
Peripheral vascular: No varicosities in lower extremities. No stasis pigmentation or ulcers Pulses. (2+ = normal)
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Radial Femoral Popliteal Dorsalis Pedis Posterior Tibial
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Rt 2+ 2+ 2+ 2+ 2+
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Lt 2+ 2+ 2+ 2+ 2+
Musculoskeletal: No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles.
Neurologic: Mental Status: Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranial nerves: II to XII intact. Motor: Good muscle bulk and tone. Strength: 5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius. Cerebellar: Rapid Alternating movements (RAMs) and point-to-point movements intact. Gait stable, fluid. Sensory: Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative. Reflexes: Bilateral triceps, brachioradialis, patellar and Achilles deep tendon reflexes intact. Bilateral plantar reflex intact. Babinski response is negative.
