AM case study 6 HISTORY AND PHYSICAL EXAMINATION
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School
Luzerne County Community College *
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Course
234
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
4
Uploaded by AgentGull2983
HISTORY AND PHYSICAL EXAMINATION
Patient’s Name:
Alexa Dooley
Patient ID:
DOO-78
DOB:
10/10/****
Age:
54
Sex:
F
Date of Visit:
06/18/****
Primary Care Physician:
Chris Salem, MD, Family Practice
REASON FOR VISIT:
Patient presents for pre-operative medical clearance. Surgery is scheduled for
06/19/****, at Hillcrest Medical Center by doctors Bernard Kester, and Mark Swafford.
MEDICATION LIST:
1.
Amber oval C/C PV-6 ounces; medical supplies; not prescribed this visit.
2.
Toprol XL, metoprolol oral tablets, extended release 50 mg; 1 T PO QD; start date 05/15/****;
not prescribed this visit.
3.
Tricor, fenofibrate oral tablets, 48 mg; 1 T PO QID; start date 05/15/****; not prescribed this
visit.
4.
Detrol LA, tolterodine oral capsules, extended release, 4 mg capsule; 1 C PO QID; start date
05/15/****; not prescribed this visit.
5.
Aspirin oral tablets, 81 mg; 1 T PO QD; OTC; not prescribed this visit.
6.
Phentermine hydrochloride, oral tablets, 37.5 mg; not prescribed this visit.
7.
Furosemide oral tablets, 20 mg; 1 T PO Q AM; not prescribed this visit.
8.
Tamoxifen citrate oral tablets, 10 mg; not prescribed this visit.
9.
Seroquel, quetiapine oral tablets, 100 mg; 1 T PO HS; not prescribed this visit.
10.
Effexor XR, venlafaxine oral capsules, extended release, 75 mg; 1 C PO HS; start date 06/11/****;
not prescribed this visit.
REVIEW OF SYSTEMS:
Constitutional: No weight change, no fever, no unusual fatigue, no night sweats.
SKIN: no itching, no easy bruising, no bleeding, no hair loss. HEAD: no trauma, no headaches. EYES: no
blurred vision, no double vision, no loss of vision, no irritation, inflammation, or pain. EARS: no pain, no
loss of hearing, no tinnitus, no motion sickness. NOSE: no coryza, no rhinitis, no epistaxis, no sinus pain.
THROAT: no soreness, no change in voice, no hoarseness, no enlarged tonsils. NECK: no swelling, no
masses, no pain with range of movement. RESPIRATORY: no chest-wall pains, no cough, no shortness of
breath, no wheezing, no hemoptysis, no PND, denies sputum production, no history of asthma, no COPD.
CARDIOVASCULAR: no chest pains, no palpitations, no dizzy spells, no shortness of breath on exertion,
no orthopnea, no pedal edema, no history of murmur, no cardiac stents, no weight change, no change in
bowel habits, no blood or mucous in stool, no increase in gassiness, no nausea, no emesis, no
hematemesis, no melaena, no BRBPR, no acute or chronic abdominal pain, no history of hepatitis, no
gallbladder problems, no rectal bleeding or hemorrhoids.
(continued)
HISTORY AND PHYSICAL EXAMINATION
Patient’s Name:
Alexa Dooley
Patient ID:
DOO-78
DOB:
10/10/****
Age:
54
Sex:
F
Date of Visit:
06/18/****
Page 2
GENITOURINARY: no dysuria, no hematuria. Patient has urge incontinence, medically managed.
MUSCULOSKELETAL: no myalgias, no arthralgias, no erythema or swelling of joints, no recurring joint
pain or swelling. NEUROLOGICAL: no weakness of the extremities, no numbness or tingling. No loss of
balance, no dizziness, no vertigo, no loss of vision, no double vision, no change in gait, no seizures.
HEMATOLOGICAL: no unusual bruising, bleeding, or clotting problems. ENDOCRINE: no heat or cold
intolerance. No unusual weight gain or loss. No polydipsia, polyphagia, or polyuria. PSYCHIATRIC: denies.
PHYSICAL EXAM:
VITAL SIGNS: BP 118/80, Height 68.5 inches, Weight 190lbs, BMI 28.47, Pulse 70 bpm,
Respiratory Rate 18 bpm. SKIN: no Rashes, no lesions, no ulcers, no unusual moles. HEAD: no masses, no
sinus pain, no sinus tenderness. EYES: PERRLA. EOMS intact. Corneas clear. Anicteric sclera. No
conjunctival inflammation. Normal vision. No lid lag or stare. No exophthalmos. ENT: Pinnae normal
bilateral. Ear canals without congestion or discharge. TM’s without erythema or bulging. Tonsils are WNL.
NECK: supple, normal ROM. No vertebral tenderness, no JVD. No bruits. THYROID: size is normal. LYMPH
NODES: no cervical axillary, or inguinal lymph node enlargement. CHEST: symmetrical. Normal chest-wall
movement. LUNGS: clear to auscultation, No rales, no wheezing, no rhonchi, no rubs. HEART: Regular
rhythm. Normal apical pulse. S1, S2 normal, no S3. No murmur, gallop or rub. ABDOMIN: positive BS in
all quadrants. Flat, soft, no tenderness, no masses, no rebound tenderness. No hepatomegaly. No
splenomegaly. No purple striae. No bruits. No femoral pulses. No hernias. G/U: no CVA tenderness.
MUSCULOSKELETAL: No kyphosis. Joints within normal ROM. No tender or swollen joints.
NEUROLOGICAL: Cranial nerves II through XII intact. Normal motor and sensory exam. Reflexes are
normal. Coordination is normal. Gait is WNL. Romberg negative. Babinski negative. MENTAL STATUS:
Rational, alert and oriented. Appropriate mood and affect.
ASSESSMENT:
Multiple chronic and stable medical conditions as per list. Medically optimized for
proposed surgical procedures. Risk level for surgical procedure; low. Patient’s clinical risk; low. Combined
risk; low. EKG normal tracing attached. Bloodwork copy attached.
(continued)
HISTORY AND PHYSICAL EXAMINATION
Patient’s Name:
Alexa Dooley
Patient ID:
DOO-78
DOB:
10/10/****
Age:
54
Sex:
F
Date of Visit:
06/18/****
Page 3
DIAGNOSES:
1.
Malaise and fatigue.
2.
Insomnia, unspecified.
3.
Hypertension, benign.
4.
Esophageal reflux.
5.
Malignant neoplasm, right breast, female.
6.
Hyperlipidemia, unspecified.
7.
Pre-operative cardiovascular exam, acute.
PLAN:
Patient instructed to stop her ASA and other NSAIDs one week prior to surgery. Patient to take
Toprol in the a.m. of surgery with small sip of water. Patient is on beta blockers and statins; she in on no
blood thinners. Patient to stop phentermine two days before surgery and resume one day after surgery.
Hold tamoxifen peri-operatively. Will follow patient in the hospital peri-operatively.
(continued)
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HISTORY AND PHYSICAL EXAMINATION
Patient’s Name:
Alexa Dooley
Patient ID:
DOO-78
DOB:
10/10/****
Age:
54
Sex:
F
Date of Visit:
06/18/****
Page 4
_____________________________________
Chris Salem, MD, Family Medicine
CS:AM
D: 06/18/****
T: 10/26/2023
C: Bernard Kester, MD, General Surgery
Mark Swafford, MD, Plastic and Reconstructive Surgery
Hillcrest Medical Center Surgical Clearance
Enclosed:
1.
EKG
2.
Bloodwork