Case 4-1 History and Physical Examination
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Lake Land College *
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064
Subject
Medicine
Date
Feb 20, 2024
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docx
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HISTORY AND PHYSICAL EXAMINATION
Patient Name:
BROWN, Stephanie
PCP:
Anderson Phipps, MD
Patient ID:
000132
Sex/Age:
F/70
DOB:
September 18, 1952
Date of Admission:
January 1, 2023
HISTORY OF PRESENT ILLNESS: Ms. Brown comes into the ER for follow-up with pansinusitis. She
could not get into the ENT clinic because of it being New Year’s Day. Her CT scan shows sinusitis everywhere. She was on Omnicef for 28 days, and she just finished 2 weeks of Augmentin. She’s
being prepared by Dr. King for possible sinus surgery if she does not improve. She still has some congestion, and she has a lot of drainage. Patient still feels a little bit of pressure. The problem before was on the right side. She feels no localized pain now. She’s admitted through the ER for observation.
PAST MEDICAL HISTORY: See review on the chart from her last visit.
PHYSICAL EXAMINATION
VITAL SIGNS: Weight 167 lbs, blood pressure 123/78, pulse 79, respirations 16.
GENERAL: She is alert and oriented x3.
EARS: Canals are clear, tympanic membranes are clear.
NOSE: Septum is straight, turbinates are pale, external nasal bones are midline.
ORAL CAVITY/OROPHARYNX: Floor of the mouth is soft, base of the tongue is soft and mobile, pharynx is clear.
NECK: No significant adenopathy. Thyroid is midline, no masses or goiter. The parotid and submandibular glands are clear.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation.
ABDOMEN: Good bowel sounds. No HSM.
NEURO: Cranial nerves II through XII are intact, no nystagmus.
DIAGNOSTIC DATA: CT scan today shows ethmoid, sphenoid, and frontal sinuses all clear. The maxillary sinuses have been operated on; they are wide, but there is a portion of the maxillary sinus that almost looks walled off.
IMPRESSION: Chronic sinusitis, improving.
RECOMMENDATIONS: Will observe patient for now. She can continue taking Mucinex, and we will deal with any problems that arise as we need to.
(Continued)
HISTORY AND PHYSICAL EXAMINATION
Page 2
Patient Name: BROWN, Stephanie
PCP: Anderson Phipps, MD
Date of Admission: January 1, 2023
Patient ID: 000132
__________________________________________
Connie C Wilder, MD, Emergency Medicine
CW:OF
D: 1/1/2023
T: 1/1/2023
C: Anderson Phipps, MD, Family Medicine/Geriatrics
Miranda King, MD, ENT
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