Comprehensive Health Case Study
:
Current [Comprehensive Health History Name of interviewer:_____________________________ Date of assignment: _______________
Identifying data | Y | N | Name of interviewer | X | | Name of patient | X | | Date and time of interview | X | | Location of interview | X | | Source of data | X | | Reliabilty of informant | X | | Ethnicity/culture | X | | Age and gender | X | | Date/place of birth | X | | | | | Chief complaint | Y | N | Chief complaint | X | | | | | Present Illness | Y | N | Onset of symptoms | X | | Timing | X | | Character, quality, quantity, location | X | | Associated events | X | | What lessens symptoms | X | | What increases symptoms | X | | Treatments …show more content…
tried and results | X | | Effects on other systems (appetite, energy, headache, etc) | X | | Effects on usual activities | X | | Other | | | | | | Past medical history | Y | N | Medical disorders | X | | Surgeries | X | | Injuries/disabilities | X | | Other hospitalizations | X | | Childhood illnesses | X | | Recent health exams | X | | Immunizations | X | | Preventive health care | X | | Other | | | | | | Medications, dosages, indications | Y | N | Prescription meds | x | | OTC meds | X | | Allergies | X | | Other | | | | | | Social history | Y | N | Marital status | X | | Family members | X | | Housing | X | | Work/occupation | X | | Education | X | | Religion | X | | Leisure activities | X | | Economic status | X | | Legal | X | | Other | | | | | | Family history | Y | N | Genogram | X | | Familial disorders | X | | FH of alcohol/drug problems, mental illness | X | | Other | | | | | | Behavioral history | Y | N | Alcohol use (current and prior use) | X | | Other addictive drugs (current and prior use) | X | | Tobacco use (current and prior use) | X | | Sexual orientation | | x | Sexual history | X | | Exercise | X | | Caffeine | X | | 24 hour dietary recall | | X | Typical dietary habits | X | | History of weight loss or weight gain | X | | Sleep patterns | X | | Work patterns | X | | Other | | | | | | General | Y | N | Vital signs | X | | Known data (height, weight, previous BP) | X | | Usual health status | x | | Additional data | | | | | | Skin and hair | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Hematologic/ immune system | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Head | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Ears | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Eyes | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Nose | Y | N | Current problems | X | | Previous problems | X | | Additional data | X | | | | | Throat | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Neck | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Chest/lungs | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Heart/circulation | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Breasts/axillae | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Abdomen | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Urinary | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Female genitalia | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Male genitalia | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Anus/rectum | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Neurological | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Musculoskeletal | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Psychiatric | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Endocrine | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Constitutional | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | |
| Total “yes”—adequately completed | Total not adequately completed | Required sections (out of 100) | 98 | 3 | Optional sections credited | | | Overall grade | 98—good job, see comments |
Name of interviewer: Kenisha Mattison Marajah RN, CNS student
Name of patient: (name change to protect privacy) Joe Brown
Date and time of interview: September 6, 2010 at 9am
Location of interview: Dialysis Room
Source of data: Patient (Mr. Brown)
Reliability of informant: alert, rationale and oriented × 3
Culture, age and gender: Hispanic 66 year old male
Chief Complaint: 66 year-old Hispanic male presents with complaint of “I am having hard time breathing and my entire body is very weak, I can hardly walk two steps without stopping for the past week”. I “feel nauseous and start vomiting on my way to my dialysis clinic” this Monday morning.
History of Present Illness (HPI): Mr. Brown a 66 year old Hispanic male at 9am this morning September 6, 2010 came to the hospital dialysis room on his way to his dialysis clinic. Mr. Brown states he was feeling well up until a week ago he began to feel tired and weak over his entire body. His weakness and tiredness was intermittent only on exertion by lifting heavy objects or walking a block. At present Mr. Brown noted that he cannot complete simple task that he could have done a week ago without resting a few minutes into the task.
Mr. Brown is a know dialysis patient who reported for his regular treatment last Friday, he told his PCP about his feeling of weakness and tiredness he was told that after his regular dialysis he would feel better. After his dialysis he went home voiced that he felt better; he was not as weak as he was in the morning he went to dialysis, he was able to do some activities of daily living without resting within a few minutes of the task.
Saturday evening Mr. Brown completed his weekend task of cleaning the outside yard and going to the grocery store. Mr. Brown voiced “when I went to bed I could not sleep I was tossing and turning all night because I could hardly breathe, I used two pillows to elevate my head with little help”. On Sunday “I did not do much, I sat on the sofa most of the day and watched television, sunday night was the same as the night before I could hardly sleep because of the difficulty I have breathing”.
On Monday morning Mr. Brown was getting ready for his scheduled dialysis, patient states he was unable to get his clothes on, his driver who was waiting was called to assist him. On his way to his dialysis clinic he began to feel nauseous and vomit mucus, his driver immediately took him to the nearby hospital emergency room, because of his known dialysis status he was referred immediately to the dialysis room. Patient states no chest pain or chest discomfort, no headache, fever, abdominal pain, diarrhea or fainting spells.
Past Medical History:
Childhood Diseases: Mr. Brown remembers having chicken pox and measles in his childhood years.
Adult Illnesses:
Diabetes mellitus: diagnosed at age 32 when he presented with fatigue, frequent urination, foot ulcers and significant weight loss he was hospitalized for two weeks.
Hypertension: During his treatment for diabetes mellitus he was also diagnosed with hypertension while hospitalized.
Chronic kidney disease: Mr. Brown was referred to a nephrologist in the same year of being diagnosed and treated for diabetes mellitus and hypertension, while he was frequently seen by a nephrologist he was told that his “kidneys are failing” and he would need dialysis or a kidney transplant in the future as the disease progresses. Patient voiced he was placed on “medications to further reduce his BP and slow the damage of his kidneys”. Mr. Brown transitioned into chronic kidney disease 10 years later at age 42 and commenced haemodialysis 3 times per week.
Past Surgical History: Internal Jugular catheter placed at the age of 42, with several catheter changes as a result of infections, an Arteriovenous fistula placed on his left upper arm at age 44 it later became thrombosed hence at age 52 he had an arteriovenous graft place on his left lower arm.
Medications: Nifedipine 120 mg po once daily to treat high blood pressure, chest pain Clonidine 0.2 mg po once daily to treat high blood pressure Lisinopril 40mg po twice daily, treat high blood pressure, slow the loss of kidney function Metopropolol 50 mg po twice daily, treats high blood pressure, slow loss of kidney function. Aspirin 81mg once daily, thins the blood, pain and fever relief Xanax 0.2 mg po prn to treat anxiety
Lipitor 80mg po once daily, reduce cholesterol Epogen 10,000u sc on dialysis days to elevate or maintain RBC, treat anemia
Allergies: Heparin, no other known allergies
Immunization: Mr.
Brown voiced receiving Hepatitis B vaccination and Influenza vaccination at his dialysis clinic; he also recalls getting tetanus shots years ago for dog bite.
Social History: Mr. Brown migrate from Mexico to the United States 40 years ago, he works at a local hardware store five days per week, and enjoys hanging out with his buddies having a drink, barbecuing or playing cards. Mr. Brown has 4 grown children three boys and one girl, he was married but after “12 years into the marriage it fell apart”, he is now divorced and single and with no significant relationships. He is not associated with any religion but remember growing up attending a Catholic church.
Behavioral History: Mr. Brown states he was a chronic alcohol drinker however when he became very sick with his diagnosis of diabetes, kidney disease and hypertension he stopped drinking; now he consumes a beer when he hangs out with his buddies once per week. He smoked a pack of cigarette for 45 years now he does not smoke. He is on Medicaid to meet his medical needs; he has never gone to see a doctor until his wife encouraged him when he began to feel ill as a result of his diabetes. At present he is a regular dialysis patient at a local clinic and sees his nephrologist whenever he has a concern or regularly on his dialysis days. Mr. Brown eats at least twice per day a renal diabetic diet, he does not exercise but walk short distances to run errands. He states he is not a drug user or addict; he …show more content…
practices safe sex and is not promiscuous.
Psychiatric History: Mr. Brown states he has never seek medical attention for any form of psychiatric illnesses however at times he gets very anxious he is treated with Xanax prn.
Family History:
Mr. Brown’s grandparents are deceased from unknown causes, his grandmother died at 88 and his grandfather died at 84 they both had 2 children one male and one female, the male died of a heart attack at age 74 and the female is Mr. Brown’s mother who is also deceased.
Mr. Brown’s mother deceased at 68 years had diabetes, hypertension, and coronary artery disease she has 6 children 4 boys and 2 girls
Mr. Brown father deceased at 74 years from a heart attack
Mr. Brown has 5 siblings one brother 68 years has diabetes, hypertension and coronary artery disease
Patient Mr. Brown is 66 has diabetes, hypertension, and chronic kidney disease
One brother severely obese with diabetes 64 years
One sister with diabetes 60 years
One brother deceased in motor vehicle accident at 49 years
One sister drug addicted to cocaine with no known medical illnesses 42
Review of the systems:
General Review of systems: Mr. Brown states he has no weight loss, he has no chest pain or other discomforts; he however complains of difficulty breathing generalized weakness, nausea and vomiting. Vital Signs BP 173/92 T 97.8 P 92 R 26 weight 98 kg height 5ft 10in BMI 31 patient is obese, oxygen saturation 92% on room air, hypoxic.
Skin and Hair Review of system:
Current problems: small bruises, dryness on lower extremities with dark areas at the ankles, no ulcers or drainage.
Previous problems: diabetic ulcers several years ago; no lesions, itching, changes in hair or nails, no moles.
Hematologic/immune system:
Current problems: Anemia treated with erythropoietin 10,000u post dialysis treatment.
Previous Problems: lengthy bleeding from previous arteriovenous fistula, no post transfusion reaction.
Head review of the system
Current problems: No headache or head trauma.
Previous problems: frequent headaches stress related relieved by Tylenol 650mg, no headaches, head injury, dizziness, lightheadedness.
Ears review of the system:
Current problems: no hearing impairment, no ringing tingling, ear ache or drainage.
Previous problems: no ringing in the ears (tinnitus), vertigo, ear infections, ear aches or discharge from the ears.
Eyes review of the system:
Current problems: glasses for reading and driving.
Previous problems: blurred vision several years ago relived by wearing glasses, no vision loss, pain, redness, swelling, tearing double vision, glaucoma, cataracts or diabetic retinopathy; last eye examination unknown.
Nose review of system:
Current problems: no current problems, no nasal congestion, flaring, bleed or injury.
Previous problems: sinusitis in high pollen seasons uses Claritin during that time , no pain, no colds or discharge, nose bleeds, pressure or polyps.
Throat, mouth and pharynx review of the system:
Current problems: several missing tooth, with brown enamel and tooth decay, no dentures.
Previous problems: tooth decays, no gum bleeding, gingivitis, sore throat or hoarseness.
Neck review of the system:
Current problems: no swelling pain, fracture or stiffness, no enlarge lymph nodes.
Previous problems: no swelling, pain, fracture or stiffness, no enlarge lymph nodes.
Chest and lungs review of system:
Current problems: mild sob, difficulty breathing, paroxysmal nocturnal dyspnea, and orthopnea.
Previous problems: chest tightness later years when smoking, no hemoptysis, wheezing, pleurisy, no pneumonia or TB, no chest injury, last x-ray done a year ago.
Heart and Circulation review of the system:
Current problems: paroxysmal nocturnal dyspnea, orthopnea, for the past week and high blood pressure for the past 20years, 2 + edema to lower extremities with discolored ankle, no chest pain or discomfort.
Previous problems: chest pain twice in the past 5 years while on dialysis relieved by GTN, reports swelling in feet occasionally when fluid overload, no palpitations, murmur, rheumatic fever, no leg cramps, clots, swelling, redness or tenderness in finger or toes.
Breast and axillae review system:
Current problems: no current problems, lumps, pain from axilla or discharge from nipples.
Previous Problems: no lumps, pain from axilla or discharge from nipples.
Abdomen review of the system:
Current problems: nausea and vomiting this morning.
Previous problems: no difficulty swallowing, no heart burn, normal stool color and size, no constipation, diarrhea or change in bowel habits, no pain, bleeding or dark tarry stool(melena), no excessive gas. Mr. Brown reports no hemorrhoids, liver, gallbladder problems no hepatitis.
Urinary review of system:
Current problems: pass minimum amount of urine for the past several years because of CKD.
Previous problems: no hematuria, dysurea, burning, urgency pain on urination, patient does not report kidney stones, flank pains, urinary infections, incontinence, dribbling or hesitancy.
Male genitalia review system:
Current problems: Report sexually active in a monogamous relationship however not much sexual interest, does not use condoms or any other form of contraceptive methods.
Previous problems: report he had STI as a teenager forgot the name, no hernia, discharge, sore, pain, swelling or drainage.
Anus and Rectum review of system:
Current problems: no current problems, no reported rectal problems, no bleed, hemorrhoid or sores.
Previous problems: no previous problems, no reported rectal bleed, hemorrhoid, sore, or pain.
Neurological review of system:
Current problems: report generalized weakness, low moods.
Previous Problems: admits to no previous neurological problems, no memory impairment, headache dizziness, vertigo, fainting spells, paralysis, seizures, numbness, tingling, tremors or involuntary movements.
Musculoskeletal review of system:
Current problems: report swelling to ankles, generalized weakness, no pain.
Previous problems: muscle and joint pains (gout) to knees in the past relieved by Tylenol and Prednisone no stiffness, backache, redness, swelling or trauma to joints or muscles, cramping occasionally on dialysis increase fluid removal.
Psychiatric review system:
Current problems: report low mood and feeling of depression as a result of present onset of systems.
Previous problems: no nervousness, tension, memory changes or suicidal ideation occasionally anxious unknown reason presently on Xanax prn.
Endocrine review of systems:
Current problems: no current thyroid
problems.
Previous problems: report intermittent anxiety in the past on xanax prn for anxiety, no previous endocrine problems, no hot or cold intolerance, no excessive sweating, thirst or hunger.
Physical Examination:
Vital signs: BP 173/92 T 97.8 P 92 R 26 weight 98 kg height 5ft 10in BMI 31 O2 92% RA
General: Middle aged 66 year old Hispanic male alert and rationale with mild sob evident when conversing more than two sentences, using abdominal muscles to breathe, mucus membranes pale and moist.
Skin: no lesions, skin dry and intact, hair and nails clean, small bruises with dryness on lower extremities with discoloration of ankles.
Hematologic: mucus membranes pale and moist.
Throat, mouth and pharynx review of the system: lips tongue pale, breathe smells like urea, no gum inflammation, and no enlarge lymph nodes.
Chest and lungs review of system: mild sob, difficulty breathing, paroxysmal nocturnal dyspnea, orthopnea, crackles in all lobes.
Heart and Circulation review of the system: right jugular distention, dyspnea, S1 S2 presents no S3, high blood pressure, 2 + edema to lower extremities with dark area.
Abdomen review of the system: no pain or tenderness or ascites, had nausea and vomiting this morning.
Neurological review of system: report generalized weakness, low moods and anxiety.
Musculoskeletal review of system: report swelling to ankles, generalized weakness, no pain.
Psychiatric review system: report low mood and feeling of depression as a result of present onset of systems.
Reference
Bickley, L. S., & Bates, B. (2009). Bates' guide to physical examination and history taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins
Current [Comprehensive Health History Name of interviewer:_____________________________ Date of assignment: _______________
Identifying data | Y | N | Name of interviewer | X | | Name of patient | X | | Date and time of interview | X | | Location of interview | X | | Source of data | X | | Reliabilty of informant | X | | Ethnicity/culture | X | | Age and gender | X | | Date/place of birth | X | | | | | Chief complaint | Y | N | Chief complaint | X | | | | | Present Illness | Y | N | Onset of symptoms | X | | Timing | X | | Character, quality, quantity, location | X | | Associated events | X | | What lessens symptoms | X | | What increases symptoms | X | | Treatments …show more content…
tried and results | X | | Effects on other systems (appetite, energy, headache, etc) | X | | Effects on usual activities | X | | Other | | | | | | Past medical history | Y | N | Medical disorders | X | | Surgeries | X | | Injuries/disabilities | X | | Other hospitalizations | X | | Childhood illnesses | X | | Recent health exams | X | | Immunizations | X | | Preventive health care | X | | Other | | | | | | Medications, dosages, indications | Y | N | Prescription meds | x | | OTC meds | X | | Allergies | X | | Other | | | | | | Social history | Y | N | Marital status | X | | Family members | X | | Housing | X | | Work/occupation | X | | Education | X | | Religion | X | | Leisure activities | X | | Economic status | X | | Legal | X | | Other | | | | | | Family history | Y | N | Genogram | X | | Familial disorders | X | | FH of alcohol/drug problems, mental illness | X | | Other | | | | | | Behavioral history | Y | N | Alcohol use (current and prior use) | X | | Other addictive drugs (current and prior use) | X | | Tobacco use (current and prior use) | X | | Sexual orientation | | x | Sexual history | X | | Exercise | X | | Caffeine | X | | 24 hour dietary recall | | X | Typical dietary habits | X | | History of weight loss or weight gain | X | | Sleep patterns | X | | Work patterns | X | | Other | | | | | | General | Y | N | Vital signs | X | | Known data (height, weight, previous BP) | X | | Usual health status | x | | Additional data | | | | | | Skin and hair | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Hematologic/ immune system | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Head | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Ears | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Eyes | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Nose | Y | N | Current problems | X | | Previous problems | X | | Additional data | X | | | | | Throat | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Neck | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Chest/lungs | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Heart/circulation | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Breasts/axillae | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Abdomen | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Urinary | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Female genitalia | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Male genitalia | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Anus/rectum | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Neurological | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Musculoskeletal | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Psychiatric | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Endocrine | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | | Constitutional | Y | N | Current problems | X | | Previous problems | X | | Additional data | | | | | |
| Total “yes”—adequately completed | Total not adequately completed | Required sections (out of 100) | 98 | 3 | Optional sections credited | | | Overall grade | 98—good job, see comments |
Name of interviewer: Kenisha Mattison Marajah RN, CNS student
Name of patient: (name change to protect privacy) Joe Brown
Date and time of interview: September 6, 2010 at 9am
Location of interview: Dialysis Room
Source of data: Patient (Mr. Brown)
Reliability of informant: alert, rationale and oriented × 3
Culture, age and gender: Hispanic 66 year old male
Chief Complaint: 66 year-old Hispanic male presents with complaint of “I am having hard time breathing and my entire body is very weak, I can hardly walk two steps without stopping for the past week”. I “feel nauseous and start vomiting on my way to my dialysis clinic” this Monday morning.
History of Present Illness (HPI): Mr. Brown a 66 year old Hispanic male at 9am this morning September 6, 2010 came to the hospital dialysis room on his way to his dialysis clinic. Mr. Brown states he was feeling well up until a week ago he began to feel tired and weak over his entire body. His weakness and tiredness was intermittent only on exertion by lifting heavy objects or walking a block. At present Mr. Brown noted that he cannot complete simple task that he could have done a week ago without resting a few minutes into the task.
Mr. Brown is a know dialysis patient who reported for his regular treatment last Friday, he told his PCP about his feeling of weakness and tiredness he was told that after his regular dialysis he would feel better. After his dialysis he went home voiced that he felt better; he was not as weak as he was in the morning he went to dialysis, he was able to do some activities of daily living without resting within a few minutes of the task.
Saturday evening Mr. Brown completed his weekend task of cleaning the outside yard and going to the grocery store. Mr. Brown voiced “when I went to bed I could not sleep I was tossing and turning all night because I could hardly breathe, I used two pillows to elevate my head with little help”. On Sunday “I did not do much, I sat on the sofa most of the day and watched television, sunday night was the same as the night before I could hardly sleep because of the difficulty I have breathing”.
On Monday morning Mr. Brown was getting ready for his scheduled dialysis, patient states he was unable to get his clothes on, his driver who was waiting was called to assist him. On his way to his dialysis clinic he began to feel nauseous and vomit mucus, his driver immediately took him to the nearby hospital emergency room, because of his known dialysis status he was referred immediately to the dialysis room. Patient states no chest pain or chest discomfort, no headache, fever, abdominal pain, diarrhea or fainting spells.
Past Medical History:
Childhood Diseases: Mr. Brown remembers having chicken pox and measles in his childhood years.
Adult Illnesses:
Diabetes mellitus: diagnosed at age 32 when he presented with fatigue, frequent urination, foot ulcers and significant weight loss he was hospitalized for two weeks.
Hypertension: During his treatment for diabetes mellitus he was also diagnosed with hypertension while hospitalized.
Chronic kidney disease: Mr. Brown was referred to a nephrologist in the same year of being diagnosed and treated for diabetes mellitus and hypertension, while he was frequently seen by a nephrologist he was told that his “kidneys are failing” and he would need dialysis or a kidney transplant in the future as the disease progresses. Patient voiced he was placed on “medications to further reduce his BP and slow the damage of his kidneys”. Mr. Brown transitioned into chronic kidney disease 10 years later at age 42 and commenced haemodialysis 3 times per week.
Past Surgical History: Internal Jugular catheter placed at the age of 42, with several catheter changes as a result of infections, an Arteriovenous fistula placed on his left upper arm at age 44 it later became thrombosed hence at age 52 he had an arteriovenous graft place on his left lower arm.
Medications: Nifedipine 120 mg po once daily to treat high blood pressure, chest pain Clonidine 0.2 mg po once daily to treat high blood pressure Lisinopril 40mg po twice daily, treat high blood pressure, slow the loss of kidney function Metopropolol 50 mg po twice daily, treats high blood pressure, slow loss of kidney function. Aspirin 81mg once daily, thins the blood, pain and fever relief Xanax 0.2 mg po prn to treat anxiety
Lipitor 80mg po once daily, reduce cholesterol Epogen 10,000u sc on dialysis days to elevate or maintain RBC, treat anemia
Allergies: Heparin, no other known allergies
Immunization: Mr.
Brown voiced receiving Hepatitis B vaccination and Influenza vaccination at his dialysis clinic; he also recalls getting tetanus shots years ago for dog bite.
Social History: Mr. Brown migrate from Mexico to the United States 40 years ago, he works at a local hardware store five days per week, and enjoys hanging out with his buddies having a drink, barbecuing or playing cards. Mr. Brown has 4 grown children three boys and one girl, he was married but after “12 years into the marriage it fell apart”, he is now divorced and single and with no significant relationships. He is not associated with any religion but remember growing up attending a Catholic church.
Behavioral History: Mr. Brown states he was a chronic alcohol drinker however when he became very sick with his diagnosis of diabetes, kidney disease and hypertension he stopped drinking; now he consumes a beer when he hangs out with his buddies once per week. He smoked a pack of cigarette for 45 years now he does not smoke. He is on Medicaid to meet his medical needs; he has never gone to see a doctor until his wife encouraged him when he began to feel ill as a result of his diabetes. At present he is a regular dialysis patient at a local clinic and sees his nephrologist whenever he has a concern or regularly on his dialysis days. Mr. Brown eats at least twice per day a renal diabetic diet, he does not exercise but walk short distances to run errands. He states he is not a drug user or addict; he …show more content…
practices safe sex and is not promiscuous.
Psychiatric History: Mr. Brown states he has never seek medical attention for any form of psychiatric illnesses however at times he gets very anxious he is treated with Xanax prn.
Family History:
Mr. Brown’s grandparents are deceased from unknown causes, his grandmother died at 88 and his grandfather died at 84 they both had 2 children one male and one female, the male died of a heart attack at age 74 and the female is Mr. Brown’s mother who is also deceased.
Mr. Brown’s mother deceased at 68 years had diabetes, hypertension, and coronary artery disease she has 6 children 4 boys and 2 girls
Mr. Brown father deceased at 74 years from a heart attack
Mr. Brown has 5 siblings one brother 68 years has diabetes, hypertension and coronary artery disease
Patient Mr. Brown is 66 has diabetes, hypertension, and chronic kidney disease
One brother severely obese with diabetes 64 years
One sister with diabetes 60 years
One brother deceased in motor vehicle accident at 49 years
One sister drug addicted to cocaine with no known medical illnesses 42
Review of the systems:
General Review of systems: Mr. Brown states he has no weight loss, he has no chest pain or other discomforts; he however complains of difficulty breathing generalized weakness, nausea and vomiting. Vital Signs BP 173/92 T 97.8 P 92 R 26 weight 98 kg height 5ft 10in BMI 31 patient is obese, oxygen saturation 92% on room air, hypoxic.
Skin and Hair Review of system:
Current problems: small bruises, dryness on lower extremities with dark areas at the ankles, no ulcers or drainage.
Previous problems: diabetic ulcers several years ago; no lesions, itching, changes in hair or nails, no moles.
Hematologic/immune system:
Current problems: Anemia treated with erythropoietin 10,000u post dialysis treatment.
Previous Problems: lengthy bleeding from previous arteriovenous fistula, no post transfusion reaction.
Head review of the system
Current problems: No headache or head trauma.
Previous problems: frequent headaches stress related relieved by Tylenol 650mg, no headaches, head injury, dizziness, lightheadedness.
Ears review of the system:
Current problems: no hearing impairment, no ringing tingling, ear ache or drainage.
Previous problems: no ringing in the ears (tinnitus), vertigo, ear infections, ear aches or discharge from the ears.
Eyes review of the system:
Current problems: glasses for reading and driving.
Previous problems: blurred vision several years ago relived by wearing glasses, no vision loss, pain, redness, swelling, tearing double vision, glaucoma, cataracts or diabetic retinopathy; last eye examination unknown.
Nose review of system:
Current problems: no current problems, no nasal congestion, flaring, bleed or injury.
Previous problems: sinusitis in high pollen seasons uses Claritin during that time , no pain, no colds or discharge, nose bleeds, pressure or polyps.
Throat, mouth and pharynx review of the system:
Current problems: several missing tooth, with brown enamel and tooth decay, no dentures.
Previous problems: tooth decays, no gum bleeding, gingivitis, sore throat or hoarseness.
Neck review of the system:
Current problems: no swelling pain, fracture or stiffness, no enlarge lymph nodes.
Previous problems: no swelling, pain, fracture or stiffness, no enlarge lymph nodes.
Chest and lungs review of system:
Current problems: mild sob, difficulty breathing, paroxysmal nocturnal dyspnea, and orthopnea.
Previous problems: chest tightness later years when smoking, no hemoptysis, wheezing, pleurisy, no pneumonia or TB, no chest injury, last x-ray done a year ago.
Heart and Circulation review of the system:
Current problems: paroxysmal nocturnal dyspnea, orthopnea, for the past week and high blood pressure for the past 20years, 2 + edema to lower extremities with discolored ankle, no chest pain or discomfort.
Previous problems: chest pain twice in the past 5 years while on dialysis relieved by GTN, reports swelling in feet occasionally when fluid overload, no palpitations, murmur, rheumatic fever, no leg cramps, clots, swelling, redness or tenderness in finger or toes.
Breast and axillae review system:
Current problems: no current problems, lumps, pain from axilla or discharge from nipples.
Previous Problems: no lumps, pain from axilla or discharge from nipples.
Abdomen review of the system:
Current problems: nausea and vomiting this morning.
Previous problems: no difficulty swallowing, no heart burn, normal stool color and size, no constipation, diarrhea or change in bowel habits, no pain, bleeding or dark tarry stool(melena), no excessive gas. Mr. Brown reports no hemorrhoids, liver, gallbladder problems no hepatitis.
Urinary review of system:
Current problems: pass minimum amount of urine for the past several years because of CKD.
Previous problems: no hematuria, dysurea, burning, urgency pain on urination, patient does not report kidney stones, flank pains, urinary infections, incontinence, dribbling or hesitancy.
Male genitalia review system:
Current problems: Report sexually active in a monogamous relationship however not much sexual interest, does not use condoms or any other form of contraceptive methods.
Previous problems: report he had STI as a teenager forgot the name, no hernia, discharge, sore, pain, swelling or drainage.
Anus and Rectum review of system:
Current problems: no current problems, no reported rectal problems, no bleed, hemorrhoid or sores.
Previous problems: no previous problems, no reported rectal bleed, hemorrhoid, sore, or pain.
Neurological review of system:
Current problems: report generalized weakness, low moods.
Previous Problems: admits to no previous neurological problems, no memory impairment, headache dizziness, vertigo, fainting spells, paralysis, seizures, numbness, tingling, tremors or involuntary movements.
Musculoskeletal review of system:
Current problems: report swelling to ankles, generalized weakness, no pain.
Previous problems: muscle and joint pains (gout) to knees in the past relieved by Tylenol and Prednisone no stiffness, backache, redness, swelling or trauma to joints or muscles, cramping occasionally on dialysis increase fluid removal.
Psychiatric review system:
Current problems: report low mood and feeling of depression as a result of present onset of systems.
Previous problems: no nervousness, tension, memory changes or suicidal ideation occasionally anxious unknown reason presently on Xanax prn.
Endocrine review of systems:
Current problems: no current thyroid
problems.
Previous problems: report intermittent anxiety in the past on xanax prn for anxiety, no previous endocrine problems, no hot or cold intolerance, no excessive sweating, thirst or hunger.
Physical Examination:
Vital signs: BP 173/92 T 97.8 P 92 R 26 weight 98 kg height 5ft 10in BMI 31 O2 92% RA
General: Middle aged 66 year old Hispanic male alert and rationale with mild sob evident when conversing more than two sentences, using abdominal muscles to breathe, mucus membranes pale and moist.
Skin: no lesions, skin dry and intact, hair and nails clean, small bruises with dryness on lower extremities with discoloration of ankles.
Hematologic: mucus membranes pale and moist.
Throat, mouth and pharynx review of the system: lips tongue pale, breathe smells like urea, no gum inflammation, and no enlarge lymph nodes.
Chest and lungs review of system: mild sob, difficulty breathing, paroxysmal nocturnal dyspnea, orthopnea, crackles in all lobes.
Heart and Circulation review of the system: right jugular distention, dyspnea, S1 S2 presents no S3, high blood pressure, 2 + edema to lower extremities with dark area.
Abdomen review of the system: no pain or tenderness or ascites, had nausea and vomiting this morning.
Neurological review of system: report generalized weakness, low moods and anxiety.
Musculoskeletal review of system: report swelling to ankles, generalized weakness, no pain.
Psychiatric review system: report low mood and feeling of depression as a result of present onset of systems.
Reference
Bickley, L. S., & Bates, B. (2009). Bates' guide to physical examination and history taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins