Health history and physical assessment

Problem List:
Active: None identified
Inactive: None identified
Risk Factors: History of smoking
No exercise
High sugar, high fat diet
February 27, 2008
9:00 a.m.
Mrs. Newland is a pleasant, 29 year old married practicing RN residing in Lucas, OH.
Referral: None
Source and Reliability: Self-referred, seems reliable.
Chief Complaint: “I am here for a physical exam.”
Present Illness: Mrs. Newland is here for a routine physical exam for nursing school.
There is no present illness.
Medications. Multivitamin daily. Depo-Provera injection every 3 months.
Allergies. No known food, drug, or environmental allergies.
Tobacco. Quit 1 year ago. Used to smoke ½ pack per day since age 17 (6 packyears).
Alcohol/Drugs: Wine one glass per month. No illicit drugs.
Personal Medical History
Childhood Illnesses: No measles, mumps, rubella, whooping cough, chicken pox,
rheumatic fever, scarlet fever or polio.
Adult Illnesses: Medical: No chronic or acute illnesses. Five male sexual partners in
total, monogamous with spouse for past 14 years. Surgical: Age 18, wisdom teeth
removed (all 4). Age 19, Lasik eye surgery (bilateral). Age 23, sutures to left knee for
laceration from falling on Swiss army knife. Age 27, cesarean section delivery for breech
presentation. Age 29, repeat cesarean section. Obstetric/Gynecologic: G2P2, 2 cesarean
births without complications. 2 living children. Menarche age 12. Last menses 2 weeks
ago. Regular menstrual periods. Depo-provera for contraception. Sexually active with
spouse, no concerns with level of sexual desire. No concerns about HIV infection.
Psychiatric: None.
Health Maintenance: Immunizations: All childhood immunizations up to date. Chicken
Pox vaccine 1996. Hepatitis B vaccine X3 1999. Tetanus shot 2001. Flu vaccine 2007
with no reaction. Screening Tests: Last Pap smear March 2007, normal results. TB skin
test 2007, negative. No mammograms. No stools for occult blood.
Family Medical History:
Father, 61, alive and well, alcoholism. Mother, 55, alive and well, migraines,
environmental allergies.
Brother, 38, alive and well. Brother 37, alive and well.
Son, 2, alive and well. Daughter, 5 months, alive and well.
Paternal grandmother died at age 81 of pulmonary embolism, had diabetes, high blood
pressure. Paternal grandfather died at age 77 of stroke.
Maternal grandfather died at age 84 of pneumonia, had idiopathic pulmonary fibrosis,
coronary artery disease, heart attack, Alzheimer’s disease, hypothyroidism. Maternal
grandmother, 86, living, has bladder cancer, high blood pressure, hypothyroidism, atrial
fibrillation, renal failure, pulmonary hypertension and heart failure.
No family history of tuberculosis, asthma, high cholesterol, arthritis, mental illness,
suicide, anemia, epilepsy.
Personal and Social History: Born and raised in Mansfield, Ohio. Obtained Bachelor’s
degree in nursing in 2003. Married at age 22. Worked as staff nurse for 2 years, and then
became full-time clinical instructor at local nursing college. Currently working toward
Master’s degree in nursing to become Family Nurse Practitioner. Has 2 children ages 26
months and 5 months. Mrs. Newland lives with her husband and 2 children in a house
they own. Does at times feel “overwhelmed” from pressures of work, school and family,
however, has good support from spouse, friends, parents and from church family. Denies
feeling depressed. She is typically awake anywhere from 5:30 am to 7:00 am and in bed
by 11:00 pm. Works 7:00 am – 3:30 pm. Usually eats dinner at her parent’s house due to
her spouse working 2nd shift.
Exercise and Diet: Gets little exercise. Diet high in fats and sugar. Drinks 1-2
cups coffee per day.
Safety Measures: Uses seat belt. Uses facial sun block daily. House is childproof.
Spouse has guns in locked gun cabinet in basement. Has smoke detectors and fire
extinguishers in every level of house.
Review of Systems
General: Good appetite. Sleeps well. Has gained about 20 pounds over past 3 years.
Skin: No rashes, lumps, sores, itching, dryness or other changes. No changes in hair or
nails. No moles, but has freckles covering arms, legs, face and back.
HEENT: Head: No headache, no history of head injury. No dizziness or lightheadedness.
Eyes: Vision good, last checked 6 months ago. No glasses or contacts. No pain, redness,
blurred or double vision. Ears: Hearing good. No ringing, earaches, or discharge. Nose,
sinuses: No problems with runny or stuffy nose, bleeding or sinus trouble. No hay fever.
Throat: No fillings, toothaches. No bleeding of gums. Last dental visit 4 months ago. No
dry mouth, frequent sore throats or hoarseness.
Neck: No lumps, goiter, pain. No swollen glands.
Breast: No lumps, pain, nipple discharge. No discomfort. Does breast self-exam every
Respiratory: No cough, wheezing, night sweats, or shortness of breath. No history of
chest x-ray. No asthma, bronchitis, emphysema, pneumonia, or tuberculosis.
Cardiovascular: No known heart disease or high blood pressure. No dyspnea, orthopnea,
chest pain, palpitations, varicose veins, edema. Has never had an EKG or other cardiac
Gastrointestinal: Appetite good; no nausea, vomiting, indigestion. No trouble
swallowing, heartburn. Bowel movements once per day, brown and soft; no changes in
bowel habits. No diarrhea or bleeding. No pain, jaundice, gallbladder or liver problems.
No food intolerance, no excess belching, no excess flatus. No hepatitis, ulcer history. No
history of gastrointestinal tests or hemoccult tests.
Urinary: No frequency, urgency, dysuria, hematuria, nocturia, or recent flank pain. Good
force of stream, no hesitancy, no dribbling, no incontinency. No frequent infections or
history of stones.
Genital: No vaginal or pelvic infections. No dypareunia. No discharge, pain, masses. No
history of STD’s. Heterosexual. No sexual concerns. Last menstrual period 2 weeks ago,
regular periods every 5 weeks since menarche at age 12. Menses lasts 5 days with
medium to light flow. No bleeding between periods. No exposure to DES. G2P2, no
abortions, no stillborn. First baby was breech. Uses Depo-Provera for birth control.
Peripheral Vascular: No intermittent claudication, leg cramps, varicose veins, clots,
edema, pain with exercise or redness.
Musculoskeletal: No muscle or joint pain, stiffness, tingling. No history of gout, arthritis,
backache. No problems with range of motion or gait. No walking aids used.
Neurologic: No fainting, seizure, motor or sensory loss. Memory good. No blackouts,
weakness, paralysis, numbness or decreased sensation. No tingling, tremors, involuntary
movements, cognitive changes, disorientation or hallucinations.
Hematologic: No anemia, easy bruising, easy bleeding, or past transfusions.
Endocrine: No thyroid trouble, heat or cold intolerance, excess sweating. No diabetes,
excess thirst or hunger. No polyuria, exopthalmia, or anorexia.
Psychiatric: No history of depression or treatment for psychiatric disorders. No
nervousness, tension. General mood is happy. No change in memory.
Physical Examination:
General appearance: Mrs. Newland is a young, healthy-appearing 29 year old woman,
well groomed, fit and in good spirits. BP 118/76, HR 82 and regular, RR 16, temperature
98.7 degrees F. She is alert and oriented X4, with an erect posture. She has a steady gait
with no physical deformities. She is able to ambulate without assistance. Her speech is
clear and hearing is normal.
Measurement: Height is 68 inches, weight 185 lbs, BMI 28. Her visual acuity is 20/20
OU on the Snellen chart.
Skin: Skin color pink. Skin warm and dry. Nails without clubbing or cyanosis. No
suspicious nevi. No rash, petechiae, or ecchymoses.
Head and Face: The skull is normocephalic/atraumatic. Medium reddish brown hair is
evenly distributed, with average texture. No alopecia or balding spots noted. Facial
expression appears happy, symmetrical. Temporal artery palpated. TMJ palpated with no
clicking or crepitus noted. Patient denies any pain or tenderness in this area. Maxillary
and frontal sinuses palpated. Patient denies pain or tenderness with palpation.
Eye: External eyes appear symmetrical in shape and position. Peripheral vision intact.
Extraocular muscle movement conjugate, without nystagmus or lid lag. Visual acuity
20/20 bilaterally. Sclera white, conjuctiva pink. Pupils are 3 mm constricting to 2 mm,
equally round and reactive to light and accommodations. Disc margins sharp; no
hemorrhages or exudates, no arteriolar narrowing. Red reflex present in both eyes.
Corneal light reflex equal in both eyes.
Ear: Acuity good to whispered voice. Bilateral ear canals pink without discharge or
foreign bodies. Bilateral tympanic membranes with good cone of light present at 5 and 7
o’clock, pearly gray in color. Bony landmarks visualized bilaterally. No perforations
noted. No cerumen noted.
Nose: External appearance symmetrical with no deformities. Nasal mucosa pink, septum
midline, no sinus tenderness.
Mouth and throat: Lips pink and moist without cracking or ulcerations. Buccal mucosa
without incidence. Tongue pink, symmetrical with no ulceration. No white or erythemic
areas noted under tongue or on floor of the mouth. Hard and soft palate intact. Anterior
and posterior pillars, uvula, tonsils and pharynx pink without exudates, swelling or
ulcerations. Uvula vibrates but remains midline upon patient speaking Ahh. Oral mucosa
pink, dentition.
Neck: Neck symmetrical with no masses or scars. Trachea midline. Neck supple; thyroid
palpable without notches or masses. No palpable cervical, preauricular, posterior
auricular, occipital, tonsillar, submandibular, submental, supraclavicular lymph nodes.
Carotid pulses palpated, no bruit auscultated. Range of motion and muscle strength
against resistance without incident.
Chest, Posterior: No areas of tenderness or abnormalities noted on posterior chest.
Thorax is symmetric with symmetrical expansion. Tactile fremitus symmetrical.
Transmitted voice sounds equal and symmetrical. Lung resonant. Breath sounds
vesicular; no rales, wheezes, or rhonchi. Diaphragmatic excursion 4.5 cm bilaterally. No
adventitious lung sounds audible. Costovertebral angel without pain upon palpation.
Chest, Anterior: Anterior thorax symmetric with good expansion. Lungs resonant.
Breath sounds equal and clear bilaterally with no rales, wheezes or rhonchi. Tactile
fremitus equal bilaterally.
Upper Extremities: Patient able to perform active range of motion of hands, arms,
elbows, and shoulders without difficulty and against resistance. No evidence of swelling
or deformity. No epitrochlear nodes palpated. Radial and brachial pulses equal
Breasts: Breasts symmetric and without dimpling or masses. Nipples without discharge.
No palpable axillary lymph nodes. No masses felt in tail of Spence. Breasts palpated and
examined while sitting with arms above head, while hands on hips leaning forward and
while lying with hands raised above head.
Neck Vessels: Head of patient elevated 30 degrees. JVP is 3 cm above the sternal angle.
Heart: Carotid upstrokes are brisk, without bruits. The point of maximal impulse is
tapping. Good S1 and S2 auscultated. No murmurs or extra heart sounds. Regular rate,
rhythm and intensity.
Abdomen: Abdomen is flat with active bowel sounds in all four quadrants. It is soft, nontender and non-distended. No palpable masses. Liver span is 8 cm in the right
midclavicular line; edge of liver is smooth and palpable 1 cm below the right costal
margin. Spleen and kidneys not felt. No Costovertebral angel tenderness. No aortic or
renal artery bruits. Femoral pulses equal bilaterally.
Lower Extremities: Bilateral lower extremities symmetrical. Skin smooth warm and dry
without hair. Bilateral popliteal, posterior tibial, dorsalis pedis pulses palpated. No
edema or varicose veins noted. Patient able to perform active range of motion with hips,
knees, ankles and feet without difficulty against resistance.
Neurological: Mental Status: Alert, relaxed, cooperative. Thought process coherent.
Oriented to person, place, time and situation. Cranial Nerves: I – not tested; II through
XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar –
rapid alternating movements, finger-to-nose, heel-to-shin intact. Gait with normal base.
Romberg – maintains balance with closed eyes. No pronator drift. Vertebrae midline. Pt.
able to actively hyperextend, rotate and bend. Sensory: Pinprick, light touch and
position intact. Stereognosis and two-point discrimination not tested. Reflexes: All deep
tendon reflexes 2 plus including: biceps, triceps, brachioradialis, patellar and Achilles.
Babinski response negative.