T.Hill_NU 514_ H & P



HISTORY AND PHYSICAL EXAMINATION FORM

Name:_____Pam T. (PT)________________________________________

Age:_61__ Gender:_F__ Primary Care Provider: Kevin Stuever, MD

Reason for last visit:____6 month check-up___

Date of last visit:__September 2010__________

Specialty Providers:__Scott Robinson, MD – Wound Healing Center; John Keller, MD – Plastic Surgeon

Reason for seeking care:__non-healing_wound on right Achilles area.

Date of last visit with specialists: Dr. Robinson – 21 Feb. 2011; Dr. Keller, March 2010.

Date of next visit if pertinent:__Dr. Robinson - March 22, 2011__

Race/Ethnicity:___Caucasian_____

Marital Status:__Married for 43 years

Employer: Retired – US Government

Position at work: Retired Administrative Assistant

Living Will: Yes__X__ No____Health Care Proxy: Yes___ No_X____

Power of Attorney: Yes____ No_X____

| CHIEF COMPLAINT (CC): |DATE of Interview: |

|“I’ve had this cough for a couple months now.” |Feb.21, 2011 |

 

 

HISTORY OF PRESENT ILLNESS (HPI):

PT presents with gradual onset of dry, intermittent cough about 6-8 weeks ago. PT states occasionally she will cough up green sputum “about size of thumbnail or smaller”, but reports mostly non-productive and dry, hacking cough; denies chest pain; c/o some shortness of air with severe coughing episodes; denies fever, chills, or night sweats. Denies HA, nasal congestion, sore throat or ear pain. States cough is intermittent, but occurs throughout the day and night until she falls asleep. Reports occasionally at night she takes Guaifenesin with codeine syrup at night to help control cough so she can sleep better; States she had a Z-pack about a month ago with no improvement. PT reports some improvement over last week or so as she just finished Augmentin 875mg QD x 10 days for cat bite. States spouse has not been ill, but grandchildren have all had viral illnesses and upper respiratory infections over last month or so, requiring some days home from school where she has been primary caregiver on those days as parents are working. Reports granddaughter also missed a week of school due to strep throat, and she watched her for several days during that week. PT reports receiving influenza vaccine in Oct. 2010. Pt has also previously received pneumonia vaccine. PT reports no pain, but rates overall or generalized discomfort from cough about 2-3 on 0-10 pain scale.

MEDICATIONS:

****See attached med list

ALLERGIES: NKDA

|Tobacco: prior smoker for 20 years; 3-5 cigarettes/day; quit 25 years ago. |

|Alcohol: rarely; 1-2 times/year. |

|Illicit Drugs: Never |

MEDICAL HX (PMH):

Childhood:                                              

Chicken pox- date unknown

Adult:

Measles 1964 or 1965

Mumps 1971

Surgical:

Tonsillectomy – age 5;

Total Hysterectomy 1990 (for endometriosis);

Bilateral cataract removal – 2010;

Bilateral Total Knee Replacement – 2008;

Ruptured Achilles tendon repair- Dec. 19, 2008; revision/ reconstruction March 2009;

Multiple surgeries March/April 2009 for complications with wound healing/skin grafts and skin graft failures.

Ob/Gyn:                                                                                 

Hx. Endometriosis (Total hysterectomy 1990)

Two vaginal deliveries – Oct. 1969; March 1972.

Psychiatric:

Treated for depression 1982. 

|Vaccinations |

|(list dates of all vaccines) |

|Polio: Feb. 1976 |Meningococcal: none |

|Hepatitis B: series of - 1994-1995; again in 2002 for low titer. |

|Influenza: Oct.2010 | Shingles: 2009 |

|Pneumovax: 2009 |Td: Nov. 1996 |

|Tdap: Feb. 18, 2011 |Varicella: (chicken pox as child) |

|MMR: reports having measles as child; had mumps while |Hepatitis A: Jan. 28, 2002; |

|pregnant 1972; | |

|Small pox vaccine: April, 1972 |TB skin test: last in 2007. |

FAMILY HX/genogram:

• Maternal grandmother – died age 51, “didn’t take her HTN meds according to my mom”;

• Maternal grandfather- “heavy smoker, died of heart attack - age early 70’s”.

• PT mother died age 62 – COPD- 2ppd smoker for 50+ years; hx alcoholism, depression; known surgeries include non-healing wound and “bladder lift”; pt. states mother had ?TB “think she tested positive for TB once and they put her on meds for it”; hx of abusing prescription drugs “Demerol”, after chronic back pain and 2-3 back surgeries.

• PT’s father – hx COPD – 2 ppd smoker for 40+ years; hx prostate ca – died age 73 from metastatic prostate ca; hx AAA- found metastatic ca when went in to repair AAA- no repair done.; also hx asthma, ? COPD.; hx “Pig valve”; hx CVA – age 70; hx hyperlipidemia.

• PT has 1 brother, still living; obese; age 65; hx back surgery; retired truck driver; lives in California.

• PT has twin ½ sisters: both still living; age 49, live in Arizona.

o 1 sister is obese, heavy smoker, hx of mental illness;

o Other sister – no known medical problems.

• PT’s son – living, age 41; hx alcoholism, depression; hx of abusing recreational drugs; hx Hershprung’s disease – multiple surgeries as infant/child; hx childhood asthma; not married, no children

• PT’s daughter – living, age 38; hx C-section, age 32; T & A, age 27; has 4 children – triplets, age 6, daughter age 5. Takes Metoprolol for palpitations.

SOCIAL HX:                

|Born in: Oakland, CA, May 2, 1949. |

|Education: 2 years college |

|Occupation: Secretary/ Administrative Assistant |Sleep patterns: (numbers of hours per night) |

| |6-8 hours/ night – goes to bed late, sleeps late; has difficulty falling asleep. |

|Family Situation: |Nutrition: (caffeine, salt intake, amount) |

|Married for 43 years; retired 2010; has triplet |Drinks approx.. 3 large cups of coffee with creamer/day; 4 (12 oz.) cans of Diet |

|grandsons age 6; granddaughter age 5; Moved to Kansas |Coke/week; |

|from Alaska after retiring 1 year ago. |salts foods regularly although reports has cut back on amount of salt added. |

|Interests/Hobbies: | ETOH Use: |Other: (work stress, anxiety) |

|Spending time with grandkids; watching |Rarely; 1-2 x/yr. | |

|TV, using computer; | |None; recently retired |

|Tobacco Use: (how much per day) none; |Exercise: (how often, duration) |

| |None; recently released (Feb. 2011) to exercise lightly after Achilles wound has finally healed. |

REVIEW OF SYSTEMS

|  |Concerning Symptom |Findings |

| | |  |

|General |Wgt Δ; weakness; fatigue; fevers | No recent hx of recent weight changes, weakness, |

| |  |fatigue or fever. |

|Skin |Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails | No hx of rashes, lumps, itching; Feb. 17 – cat |

| | |bite – completed 10 days of Augmentin 875mg po QD |

| | |– no complications – good healing noted; No |

| | |changes in moles, including size or color; no |

| | |changes in hair/nails; |

|Head |Headache; head injury; dizziness | No hx of migraines, dizziness or lightheadedness |

| | |or head injury; |

|Eyes |Vision Δ; corrective lenses; last eye exam; pain; redness; excessive| Bilateral cataract surgeries 2010 – had mild |

|  |tearing; double vision; blurred vision; scotoma |cataracts bilaterally until hyperbaric oxygen tx |

| | |for Achilles injury/ poor wound healing in 2009 – |

| | |caused rapid progression of cataracts; wears |

| | |corrective lenses for driving; wears glasses for |

| | |magnification while reading. |

|Ears |Hearing Δ; tinnitus; earaches; infections; discharge | No recent changes in hearing; No c/o tinnitus, |

| | |vertigo, ear aches or discharge. |

|Nose/ |Colds; congestion; discharge; itching; hay fever; nosebleeds | No hx of sinus infections, nasal stuffiness, |

|Sinuses | |discharge, epistaxis or pruritis. No hx of |

| | |allergies, itching, or hay fever. |

|Throat |Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; | No hx of dysphagia, difficulty chewing, |

| |sore throats; hoarse |hoarseness, bleeding. Has c/o dry mouth in |

| | |mornings last 2-3 months; resolves throughout day;|

| | |Denies bleeding gums; has lots of dental work, |

| | |including bridges, crowns and fillings; has own |

| | |teeth; good dental hygiene; denies sore |

| | |throat/tongue; last dental exam/cleaning- 3/3/11- |

| | |no new findings. |

|Neck |Lumps; swollen glands; goiter; pain; neck stiffness | No hx of stiffness, tenderness, swollen glands or|

| | |lumps. |

|Breasts |Lumps; pain; discomfort; nipple discharge | No c/o lumps, pain, tenderness, or discharge; |

| | |last mammogram in 2010– normal findings. |

|Pulmonary |Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; | Hx of chronic non-productive cough for several |

| |pleuritic pains |weeks; Is known side effect of Lisinopril; no c/o |

| | |difficulty breathing at rest or with exertion; no |

| | |hemoptysis; |

|Cardiac |Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; | Denies chest pain/discomfort; no hx of |

| |edema |palpitations; denies dyspnea/orthopnea PND or |

| | |edema; |

|G/I |Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; | No recent appetite changes; no jaundice; denies |

| |belching/flatulence; Δ in bowel habits; hematochezia; melena; |n/v/d; hx heartburn/GERD – takes Prilosec; hx |

| |hemorrhoids; constipation; diarrhea; food intolerance |hiatal hernia; No recent changes in bowel habits; |

|Urinary |Frequency; nocturia; urgency; dysuria; hematuria; incontinence | Tx for UTI with Cipro 500mg BID x 7 days Feb. |

| |MALES:  caliber of urinary stream; hesitancy; dribbling |2011 – resolved; No current c/o urinary frequency,|

| | |urgency, dysuria, hematuria; c/o dribbling and |

| | |stress incontinence “when coughing” last several |

| | |years- no specialist consultations or surgeries – |

| | |states “I don’t think it’s that much of a problem;|

| | |no c/o hesitancy. |

|G/U |Sexual habits; interest; function; satisfaction; use of birth | Denies c/o or concerns. Denies HIV exposure. |

|(General) |control methods; HIV exposure | |

|Male G/U |Discharge from or sores on penis; testicular pain/masses | N/A. |

|Female G/U |Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: |age of menarche – age 11; heavy menstrual cycles |

| |bleeding between menses or after intercourse; LMP |due to endometriosis - Hysterectomy 1990; last |

| |Vaginal discharge; itching; sores; lumps Menopause; hot flashes; |normal PAP – 2007 – told she didn’t need a PAP |

| |post-menopausal bleeding; |anymore; denies hx of hot flashes; denies vaginal |

| | |bleeding/discharge/sores/lumps. |

|Peripheral Vascular |Claudication; leg cramps; varicose veins; hx of blood clots | Normal exam by vascular surgeon Spring 2010 after|

| | |appointment to check for PVD – negative; |

| | |Ultrasound for PVD - normal, no evidence of PVD; |

| | |Also had ultrasound to check for AAA since family |

| | |hx – normal ultrasound – no evidence of AAA. Right|

| | |Perineal artery occluded on ultrasound– good |

| | |collaterals – possibly related to knee replacement|

| | |sx- unknown length of time. No hx of varicose or |

| | |spider veins; wears compression stocking on right |

| | |leg after Achilles injury. No hx of blood clots. |

|Musculo-skeletal |Muscle or joint pain; joint stiffness | Hx arthritis in hips/knees. Treated with Celebrex|

| | |200mg QD. Takes Neurontin for sciatica. |

|Neuro |Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; | No hx of syncope, seizures, weakness, paralysis, |

| |involuntary movements |tremors or involuntary movements; c/o occasional |

| | |numbness/tingling to bilateral hands - ? r/t |

| | |bilateral carpal tunnel syndrome secondary to |

| | |typing and being secretary for 26+ years; |

|Heme |Hx of anemia; easy bruising or bleeding; blood transfusions | No ecchymosis, petechiae, or bleeding c/o; no hx |

| | |of anemia; hx blood transfusions – after |

| | |hysterectomy 1990 and after bilateral knee |

| | |replacements in 2008; |

|Endo |Heat or cold intolerance; excessive sweating; polydipsia; |No c/o heat or cold intolerance; denies excessive |

| |polyphagia; polyuria;  glove or shoe size |sweating; no c/o polydipsia/polyphagia or |

| | |polyuria; wears size 10 shoes – wide – unable to |

| | |wear closed heel shoes on right foot since |

| | |Achilles surgery;   |

|Psych |Nervousness/anxiety; depression; memory changes; suicide attempts | No hx of nervousness/anxiety, memory changes or |

| | |suicide attempts; brief tx for depression in 1982.|

| | |Reports depression resolved; |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download