- Published: January 21, 2022
- Updated: January 21, 2022
- University / College: Oregon State University
- Level: Doctor of Philosophy
- Language: English
- Downloads: 24
No significant family history in parents. Both parents alive, active and healthy.
Personal and social history
Married for 28 years. Has 6 children between 10- 25 years ago. Works as Sales Clerk Manager at a departmental store enjoys knitting and sewing, acts as Girl Scout Troop Leader and leads an educational course at her Catholic church.
Exercise and diet: Exercises 2-3 times a week and gets most exercise by chasing her children. Takes diet appropriate for hypercholesterolemia. Takes a multivitamin once a day.
Safety measures: Ask about the use of seat belts, sunblock, etc.
Ask h/o eyeglasses, hearing problems, vertigo, tinnitus, sinusitis, recurrent nasal allergy, hay fever?
Neck: Any pain, goiter, lumps, swollen glands?
Breasts: H/O of cyst removal four years ago. Ask h/o recurrence of cysts, lumps, pain, nipple discharge. Ask if examines breast regularly one-self
Cardiovascular: Ask h/o blood pressure, chest pain, palpitations, chest tightness, dyspnoea, orthopnea. Ask h/o ECG taken
Gastrointestinal: Ask h/o of appropriate appetite, nausea, vomiting, indigestion, the regularity of bowel movements. Ask h/o change in bowel movements, constipation, diarrhea
Urinary: Ask h/o dysuria, hematuria, recent flank pain, nocturia, dribbling of urine while coughing
Genital: Ask h/o vaginal or pelvic infections. Ask h/o dyspareunia
Musculoskeletal: Ask h/o back pain or pain elsewhere
Psychiatric: Ask h/o depression
Neurologic: Ask h/o seizures, fainting, motor or sensory loss.
Physical Examination
Describe her appearance, temperament, dress sense, color and comfort level.
Vital signs
No fever, pulse rate 69 per minute, respiratory rate 28 per minute, blood pressure- 136/78 per minute.
Skin
Look for pallor, icterus, cyanosis, lymph node, edema, rash, koilonychia
HEENT
Examine the eyes with torchlight, the retina with an ophthalmoscope, the ears with otoscope and nostrils and throat with torchlight. Look for symmetry of pupil, reaction to light and color of the conjunctiva. Look at the tympanic membrane. Look for congestion of the throat, tonsillar enlargement, flaring of nostrils and postnasal drip.
