NSG 500 Comprehensive History & Physical Exam
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School
Wilkes University *
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Course
500
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
4
Uploaded by MinisterGuanaco3468
ID:
T.J. a 28-year-old African American
CC:
"I came in because I’m required to have a recent physical exam for the health insurance
at my new job.”
HPI:
Ms. Jones comes in for a general physical exam. She has asthma and type 2 diabetes.
She is currently taking metformin 850 mg twice daily for diabetes, and birth control for
PCOS. Her diabetes is controlled with metformin, diet, and physcial activity.
Past Medical and Surgical History
PCOS, Asthma, and diabetes. No history of surgery.
Medications and Allergies
Metformin 850 mg twice a day five months ago. Birth control one pill daily. Flovent inhaler
for asthma twice a day. Allergic to cats. Advil for menstrual cramps as needed.
Family History
Mother: Alive. High cholesterol. Hypertension.
Father: Diabetes. High cholesterol. Deceased at age 58 in a car accident a year ago.
Sister: Asthma.
Brother: No significant medical condition
Paternal grandmother: Still alive. High cholesterol. NTN.
Paternal grandfather: Deceased. Had colon cancer, high blood pressure, diabetes.
Maternal grandmother: Deceased at age 73. Had stroke, HTN, and high cholesterol.
Maternal grandfather: Deceased at age 80 from a heart attack. Had high blood pressure and
high cholesterol.
Social History
Single, never married. Denies smoking cigarette. Drinks socially. Denies substance use.
Enjoys reading books. Walks for 30 or 40 minutes four or five times a week. Eats healthy
diet.
Review of Systems
Hair, skin, and nails:
Denies rash, redness, or lesions. Denies mole changes.
HEENT:
Denies hearing loss or visual change. No sinus pressure. No eye or ears pain. She
wears eyeglasses. Denies difficulty swallowing.
Respiratory:
Denies SOB, cough, and wheezing.
Cardiovascular:
Denies chest pain, heart palpitation, or edema in upper and lower
extremities.
Gastrointestinal:
Denies abdominal pain, nausea, vomiting, constipation, and diarrhea.
Denies loss of appetite.
GU:
Denies painful urination, excessive amount of urine, urinary frequency.
Musculoskeletal:
Denies joints and muscle pain. Denies joints swelling. Denies muscle
weakness.
Neurological:
Denies headache, dizziness, tingling sensation, seizures, and tremors.
Psychiatric:
Denies mood changes. Denies anxiety and depression.
Objectives Data
BP: 128/82, HR: 78, RR:15, O2: 99%, T: 99.0, BG: 100
Height: 170 cm tall, Weight: 84 kg, BMI: 29
Physical Examination
General:
Cooperative, calm, and appropriate. She is a reliable source. She appears well-
nourished and dresses appropriately for the weather. She reports recent weight loss. Denies
fever, fatigue, and chills.
Hair and Skin:
intact, warm to touch. No rash or lesions. Denies rash, redness, or lesions.
No mole changes. Skin is intact and warm to touch. Hair is evenly distributed. Skin
discoloration on neck.
HEENT:
Face symmetrical. Normocephalic head. No lesions, masses, or tenderness. Hair is
evenly distributed. White sclera. Moist and pink conjunctiva with no drainage. Mucous
membrane moist and pink. Gag reflex present. Tonsils 2+ bilaterally, not touching.
Tympanic membrane pearly grey with no discharge. No palpable lymph nodes. No goiter.
Full ROM, no jaw clicks. No sinus pain or pressure.
PERRLA, EMOs intact. Hearing intact.
She wears eyeglasses. No difficulty swallowing. No clicks or jaw palpation, full ROM.
Trachea midline. Thyroid palpable, no nodules or goiter. Lymph nodes are not palpable.
Extremities:
Brachial and radial pulses 2+. Capillary refill less than 3 seconds.
Cardiovascular:
No edema or JVD. Carotid 2+, no thrill. S2 and S2 noted. No murmurs. PMI
nondisplaced. Capillary refills less than 3 seconds.
Respiratory:
Chest walls are symmetrical. No accessory muscle use. Equal breath sounds.
Clear lung sounds. Chest resonant on percussion. Chests rises and expands equally. No
adventitious sounds, crackles, wheezing, rhonchi.
Gastrointestinal:
Abdomen round and soft. Normoactive bowel sounds are present in all
four quadrants. No palpable masses or tenderness. No guarding or distention.
Musculoskeletal:
Steady gait. Upper and lower extremities 5+. Maintain full resistance of
muscle. No swelling, deformity, masses, or redness upon inspection. Full ROM, 5+ strength
in extremities. 2+ deep tendon reflexes.
Neurological:
Sensation intact. No difficulty performing repetitive alternating movement.
Heel down shin with no deviation. Alert and oriented to person, place, year, and situation.
Reduced monofilament test.
Assessment and Plan
Ms. Jones’ BMI indicates that she is overweight. She has asthma and diabetes. She has
discoloration on her neck, a skin condition known as acanthosis nigricans that causes dark
discoloration in armpits, neck, and groins (Mayo Clinic, 2022). Acanthosis nigricans is
mostly caused by insulin resistance, cancer, and certain drugs and supplements. The risk of
acanthosis nigricans is higher in people who have obesity and type 2 diabetes (Mayo Clinic,
2022). Ms. Jones will be referred to a dermatologist to treat acanthosis nigricans. There is
no specific treatment for acanthosis nigricans and treating the underlying cause might help.
If acanthosis nigricans is caused by obesity, losing weight may help. Prescription creams,
ointments, special soaps, medications, and laser therapy can also be used to treat it.
Monofilament test shows reduced sensation in both feet. If the monofilament was not felt in
a particular site on the foot, it suggests loss of protective sensation that indicates diabetic
neuropathy or nerve damage. Clinical symptoms of diabetic neuropathy include loss of
sensation and burning pain in the feet (Feldman, 2023). There is no cure for diabetic
neuropathy; however, controlling blood sugar levels is the key to preventing or delaying
nerve damage. Diabetic neuropathy can be managed by controlling blood sugar levels,
lifestyle modifications, specifically diet and exercise, proper foot care, and managing pain
caused by neuropathy (Feldman, 2023). Because people with diabetic neuropathy do not
always feel pain when there is an injury or wound on the foot, it is important to educate Ms.
Jones to check her feet daily for cuts, blisters, and abrasions. She also needs to see a
podiatrist regularly to check foot health and help maintain skin and nails.
References
Cobb. (2023). Everything You Need to Know About Acanthosis Nigricans. Healthline.
Retrieved November 8, 2023, from
https://www.healthline.com/health/acanthosis-
nigricans
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Feldman, E. (2023). Patient education: Diabetic neuropathy (Beyond the Basics). UpToDate.
Retrieved November 8, 2023, from
https://www.uptodate.com/contents/diabetic-
neuropathy-beyond-the-basics
Mayo Clinic. (2022). Acanthosis nigricans. Mayo Clinic. Retrieved November 8, 2023, from
https://www.mayoclinic.org/diseases-conditions/acanthosis-nigricans/symptoms-
causes/syc-20368983