Symptoms Check Up. Pt. Currently

¶ … Symptoms

Check up. Pt. currently taking birth control pills (Yasmine), Zyrtec. Allergies: Penicillin

Pt hx: 35-year-old female. Denies tobacco use. Occasional alcohol use.

Surgery hx: Gastric band 2007, C-section 2007, D&C after miscarriage 2006, C-section 2004,

tonsillectomy 1981

Medical history: Denies history of DM, CVD, asthma, seizures, head injuries, back injuries, chronic stomach problems. Admits history of HTN. GU and MS histories negative.

Today's Exam: A&OX3. Alert, cooperative, dress appropriate, behavior appropriate.

Affect: Appears frustrated.

Hygiene: Extremely clean, clothing clean and neat. No odors noted.

Vital signs: T=98.8; P=72; R=15; BP=118/72; Ht.=68 inches; Wt.= 229 lbs.

Pain Scale: (0-10) Grade= 2

Skin

Color/texture: pink, soft, dry, cool

Turgor: Brisk. Returns to place in less than 2 seconds. No tenting.

Nevi: 3mm brown nevus on left cheek, 2mm brown nevus on left breast, 5mm brown nevus on right breast, 1mm brown nevus on interior right elbow- all borders regular, all color uniform

Nail beds are pink, no clubbing of fingers. No edema noted. Small skin tags on eyelids, neck, and underside of upper arms.

Hair is blonde, full, evenly distributed, medium texture. One tattoo on left shoulder. Single piercings in both ears, right nipple.

Head & Neck

Scalp is pink without lesions or tenderness. Head is symmetrical and facial features are well spaced. Nose midline with pinak and dry nasal mucosa. Septum normal. Sinuses upon palpation are non-tender. Trachea is midline. Lymph nodes are non-palpable. Full ROM of neck.

Eyes

Eyes are slightly asymmetrical- right eye approximately 5mm higher than left eye. No lid lag. No leasions or drainage. Conjunctivae are pink and moist. Sclera is clear, moist, and white. Cornea is smooth, moist, and clear. Iris is green and clear. There is no eythema, edema, or tenderness in the lacrinal area. PERRLA (4mm). Visual acuity (Snellen chart) without correction. Right eye: 20/100; left eye: 20/100. Both eyes: 20/100.

Ears

No leasions, includes, or drainage of ears noted bilaterally. Repeated 4 of 6 letters/numbers whispered at 4 feet from right ear. Repeated 6 of 6 letters/numbers whispered at 4 feet from left ear.

Mouth & Pharynx

Words spoken clearly. Lips pink, moist, symmetrical, with some evidence of chapping. Tongue is pink, moist, midline, with one lesion (subject reported biting tongue when asked about the lesion). Buccal mucosa intact, pink, and moist. 31 teeth are present, and appear well kept- top left incisor removed. Uvula midline and soft and hard palates rise symmetrically. Tonsils and adenoids removed. Pharynx is midline.

Neuro

Alert and oriented to time, place, and person. Gait smooth. Somewhat agitated. Answers questions appropriately. Distinguishes between sharp and dull touch and warm and cold temperatures.

Lungs & Thorax

AP diameter to transverse diameter 1:2. Chest rises and falls symmetrically without retractions, bulges at the ICSs or use of accessory muscles. Skin is pink and nipples symmetrical. No tenderness, pulsations, masses or crepitus. Scapule and shoulders equal height. Vesicular sounds prevail over the lung fields. Bronchovesicular sounds heard at the first and second ICS lateral to sternum. Bronchial sounds heard over trachea. No adventitious sounds heard.

Cardiovascular

No nodules, masses, or lesions on the precordium area. Precordium without thrills, heaves, pulsations. PMI is palpated at the 4th left ISC midclavicular line. S1 is head at the loudest at the apex. S2 is heard loudest at the base. No adventitious sounds noted. Apical pulse= 68,

Peripheral Vascular

Skin over extremities cool, pink, and dry. Hair distribution difficult to determine- subject reports laser hair removal. Pulsation in carotids visible. Temporal, carotid, apical, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are +2. Capillary refill

Musculoskeletal

Posture erect while standing. Gait steady. Skin pink over extremeties. Muslces equal in size and shape bilaterally, with the exception of the biceps- right bicep larger in size and more defined in shape than left bicep. No hypotonicity or atrophy noted. Spinal column is midline without deviation. Grip strength rated a 5/5 bilaterally. Full resistance of lower extremities noted 5/5. Full ROM in all joints.

Abdomen

Skin over abdomen is pink. No pulsations visible. Active bowel sounds in all 4 quadrants. Contour is rounded. Faded scar over uterus. Significant loose skin over abdomen, resulting in an apron of skin. No rashes or hygiene issues noted. Inguinal nodes not nonpalpable.

Breast Self-Exam

The information in this guide is adapted from guidelines published by the American Cancer Society in September, 2009, and includes changes from prior instructions for breast self-exam.

First, you should do self-exams at the same time of each monthly cycle, because of normal cyclical changes in breast size and shape. First, you should lie down and place your right arm behind your head. Using the finger pads of your index, middle, and ring fingers of your left hand, use dime-sized circular motions to feel breast tissue. Each area should be examined with three different levels of pressure; light, medium, and firm; to assess the different tissue levels. Move around the breast in an up and down pattern, beginning at the middle of the underarm, moving down, and then going all the way to the middle of the chest bone. All areas in the chest should be felt, from the ribs up to the neck or clavicle. Next, examine the underarm area, by removing the arm from behind your head, so that the arm muscles relax. Repeat the exam on your left breast, placing left arm behind head, and using your right hand to do the exam (ACS, Breast, 2009).