SKILLS for PATIENT ASSESSMENT H & P FORM



HISTORY AND PHYSICAL EXAMINATION FORM

Name: Patient Amy Higgins, Interview done by Diane Morris 2/24/2011

Age: 35 Gender: Female

Primary Care Provider: Dr Scott Nitzel

Reason for last visit: Physical

Date of last visit: six months ago

Reason for seeking care: Intermittent Right Upper Quadrant

Specialty Providers: Dr Snider/OBGYN

Date of last visit with specialists: March 23, 2010

Date of next visit if pertinent: March 13, 2011

Reason for seeking care: Routine Exam

Race/Ethnicity: White

Marital Status: Married

Employer: Olathe Medical Center/Children’s Mercy Hospital

Position at work: Emergency room RN/Emergency contact center

Living Will: Yes____ No__X

Health Care Proxy: Yes____ No__X___

Power of Attorney: Yes____ No__X___

 

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|CHIEF COMPLAINT (CC): |DATE: Off and on for the last nine to twelve months.   |

| Intermittent right upper quadrant pain with radiation into right| |

|shoulder area, indigestion, increase belching, nausea with pain | |

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HISTORY OF PRESENT ILLNESS (HPI):

Onset: Symptoms started nine to twelve months ago, pain and nausea comes on gradually

Location: Right Upper Quadrant (RUQ) with radiation into right shoulder

Duration: Pain has been intermittent for the last nine to twelve months, pain can last anywhere from a couple of hours, to a day to a couple of weeks and then go away for a month or two, episodic

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Character: gnawing pain that becomes sharp and stabbing, burning in chest area

Aggravating and associated factors: some food (raw vegetables and nuts are the worst), increase in belching, indigestion, nausea due to the pain, diarrhea occasionally, no fever or chills

Relieving factors and effects on the problems: belching to get rid of gas (bloating), TUMS for the indigestion, laying down, occasionally Motrin or Tylenol, watching what food I eat for a couple of days

Frequency of attacks: Typically two to three times a week, can last for one to a couple of weeks then go away for a couple of months, pain and nausea begin then the belching which lasts for a couple of hours

Severity: three out of ten, doesn’t normally change work or lifestyle, I just watch what I eat for a couple of days

 

MEDICATIONS: (List brand and trade name, dosage, frequency and reason for taking).

TUMS (calcium carbonate) takes occasionally for heartburn/indigestion

Tylenol (acetaminophen)/Motrin (Ibuprofen) takes occasionally for pain

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ALLERGIES:   (Ask about Drugs, Environmental, Food and Other Allergies, Describe Reaction)    

NKDA

Latex Sensitivity: hands become red and itching; mouth had a funny feeling while at the dentist office

No food allergies

SOCIAL HISTROY:

Tobacco: No

Alcohol: two to three times a week

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Illicit Drugs: No                                                                

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MEDICAL HX (PMH):

 

Childhood:                                                                             Adult:

 Chickenpox at 5 years of age No medical problems or

  injuries

Surgical:

C-section times two 2003 and 2006

 

 

               

Ob/Gyn:                                                                                  Psychiatric:

 Ruptured right ovarian cyst times two, no surgery No problems

 

 

|Vaccinations |

|(list dates of all vaccines) |

|Polio: child |Meningococcal: |

|(unsure of date) |Child (unsure of date) |

|Hepatitis B: series of three in 1995 |

|Influenza: 2011 | Shingles: no |

|Pneumovax: |Td: |

|No |No |

|Tdap: 2010 |Varicella: No vaccine, |

| |had chickenpox as a child|

|MMR: child (unsure of |Hepatitis A: |

|date), booster in 2009 | |

| |No |

 

FAMILY HX: (specify family member affected/age at death, list grandparents, parents, & siblings)

|HTN: Mom and Brother |Renal : None |

|DM: None |Thyroid : None |

|Cancer: Breast Aunt and Grandma |TB: None |

|MI/CAD: Grandma (mom’s side), AAA and |Suicide: None |

|triple bypass, Grandpa AMI, passed | |

|away in his 40’s, Dad Idiopathic | |

|Avascular necrosis, High Cholesterol | |

|CVA: None |Alcoholism: None |

| Psychiatric: Anxiety/Depression Mom |Substance Abuse: none |

|and Brother | |

 

 

SOCIAL HX:                

|Born in: Missouri 1975 |

|Education: BSN in Nursing, going for maters Degree at Washburn University |

|Occupation: Emergency Room RN |Sleep patterns: (numbers of hours per night): eight hours per night |

|Family Situation: married with two children, |Nutrition: (caffeine, salt intake, amount): |

|parents are still married |One cup of coffee, one coke per day, lots of salt |

|Interests/Hobbies: Reading, scrap| ETOH Use: |Other: (work stress, anxiety): Full time |

|booking, school |two to three times a week |school, Part time work, two children with|

| | |activities, worried about school |

|Tobacco Use: (how much per day) |Exercise: (how often, duration) |

|none |Not enough would like to do more |

Review of Symptoms (ROS)

List findings or check as negative.

REVIEW OF SYSTEMS

|  |Concerning Symptom |Findings |

| | |  |

|General |Wgt Δ; weakness; fatigue; fevers | denies |

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|Skin |Rash; lumps; sores; itching; dryness; color change; Δ in | denies |

| |hair/nails | |

|Head |Headache; head injury; dizziness | denies |

|Eyes |Vision Δ; corrective lenses; last eye exam; pain; redness; | Glasses for near sighted, last exam one year |

|  |excessive tearing; double vision; blurred vision; scotoma |ago |

|Ears |Hearing Δ; tinnitus; earaches; infections; discharge | Denies |

|Nose/ |Colds; congestion; discharge; itching; hay fever; nosebleeds | Denies |

|Sinuses | | |

|Throat |Bleeding gums; dentures; last dental exam; sore tongue; dry | Denies, last dental exam six months ago |

| |mouth; sore throats; hoarse | |

|Neck |Lumps; swollen glands; goiter; pain; neck stiffness | Swollen glands right side of neck |

| | |(submandibular/post cervical chain), US done |

| | |WNL, denies any other symptoms |

|Breasts |Lumps; pain; discomfort; nipple discharge |Denies |

|Pulmonary |Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; | Denies |

| |pleuritic pains | |

|Cardiac |Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; | Palpitations at night while laying on left |

| |edema |side, no other symptoms |

|G/I |Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; | Nausea, indigestion, increase in belching, |

| |belching/flatulence; Δ in bowel habits; hematochezia; melena; |diarrhea occasionally |

| |hemorrhoids; constipation; diarrhea; food intolerance | |

|Urinary |Frequency; nocturia; urgency; dysuria; hematuria; incontinence | Denies |

| |MALES:  caliber of urinary stream; hesitancy; dribbling | |

|G/U |Sexual habits; interest; function; satisfaction; use of birth | One male partner, denies use of BCP, HIV test|

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

|Male G/U |Discharge from or sores on penis; testicular pain/masses | NA |

|Female G/U |Menarche; frequency/duration of menses; dysmenorrhea; PMS |LMP 2/12/2011, pain with ovulation, denies any|

| |symptoms: bleeding between menses or after intercourse; LMP |other symptoms |

| |Vaginal discharge; itching; sores; lumps Menopause; hot flashes; | |

| |post-menopausal bleeding; | |

|Peripheral Vascular |Claudication; leg cramps; varicose veins; hx of blood clots | Varicose and spider veins |

|Musculo-skeletal |Muscle or joint pain; joint stiffness | Normal aches and pains |

|Neuro |Syncope; seizures; weakness; paralysis; numbness/tingling; | Denies |

| |tremors; involuntary movements | |

|Heme |Hx of anemia; easy bruising or bleeding; blood transfusions | Denies |

|Endo |Heat or cold intolerance; excessive sweating; polydipsia; | Denies, shoe and glove size 8 to 8.5 |

| |polyphagia; polyuria;  glove or shoe size | |

|Psych |Nervousness/anxiety; depression; memory changes; suicide attempts| Denies |

PHYSICAL EXAMINATION

 

|Appearance: Patient appears well groomed: cognitive, emotional stability, and speech and language all are WNL  |

|Vital Sign:    BP:  105/62     HR:  74     RR:  16   Temp: 98.2 |

|Skin: |Pink, soft, warm and dry to the touch, skin turgor ................
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