History and Physical Examination

Patient Name: S.M.

Address: 123 ABC Street Milledgeville, Ga 31061
Date of Service: 6/11/14
Referral Source: Walk-In
Data Source: Patient
Chief Complaint: S.M. is a 44 y/o Caucasian female having left knee pain, left calf pain and
swelling in left leg for two weeks.

History of Present Illness

The patient is a 44 y/o Caucasian female with a history of pancreatitis, hypertension,
hyperlipidemia, arthritis, SVT during pregnancy and morbid obesity who presents to the
healthcare clinic with a recent 2 week history of left knee pain, left calf pain and swelling from
her left knee extending to her left foot. Denies trauma, and injury to left lower extremity. The
pain began Monday afternoon while the patient was working at Central State Hospital. The onset
was gradual and the pain is described as a constant aching, throbbing pain. Exacerbated by
walking and standing (Rated an 8/10). Alleviated by sitting, resting, and lying down (Rated a
5/10). The left knee and left calf pain is described as a dull, aching pain without weight bearing
to the left lower extremity. Currently taking Voltaren SR 75 mg BID and Ibuprofen 800 mg every
6-8 hours which aides in relieving the pain (Rated a 3/10). She reported a steroid injection was
performed approximately three months by Dr. Slappy and was helpful in controlling the left knee
pain for two months. Prior to the left knee steroid injection she reported the pain an 8/10 and post
procedure a 2/10. Dr. Slappy has recommended a possible left knee replacement. The pain
interferes with the patients activities of daily living by her inability to sleep, interferes with her
relationships, work and limits her physical activities. Patient has reported a sedentary lifestyle
due to pain.
She is noncompliant with her prescribed cholesterol medication due to fear of side effects.
Patient reported Lipitor caused aching in joints. Declined to take another medication for
cholesterol since 1995. Last total cholesterol 214 per patient and date unknown.
Current Medications
ASA 81 mg tablet PO Daily
Lasix 40 mg tablet PO Daily
Multivitamin with mineral OTC 1 tablet PO Daily
Voltaren SR 75 mg tablet PO BID
Omeprazole Magnesium 20.6 mg capsule PO Daily
Atenolol 100 mg tablet PO Daily

Ibuprofen 800 mg tablet PO every 6-8 hours

Allergies
Protonix causes hives, itching
Lipitor causes aching in joints
Past Medical History
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7.

Arthritis diagnosed in 2013

Pancreatitis diagnosed in 1998
SVT during second pregnancy diagnosed in 1996
Hypertension diagnosed in 1995
Hyperlipidemia diagnosed in 1995
Gastroesophageal reflux in 1995
Morbidly Obese diagnosis date Unknown

Usual childhood illnesses. No history of rheumatic fever. Denies having transfusions.

Past Surgical History

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2.
3.
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5.

Salivary duct removed in 2007

Tonsillectomy and Adenoidectomy in 2006
Cholecystectomy and umbilical hernia repair in 2005
Rhinoplasty in 2005
Extraction of wisdom teeth in 1986

Denies complications with anesthesia. No family history of adverse reaction to anesthesia. Will
accept blood transfusions if needed.

Hospitalizations
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2.
3.
4.
5.
6.

Pancreatitis contributed to use of HCTZ 2/2014

Tonsillectomy and Adenoidectomy in 2006
Cholecystectomy and umbilical hernia repair in 2005
Rhinoplasty in 2005 for deviated septum
Vaginal childbirth in 1993 and 1996
SVT during pregnancy 1996

Vaccinations

The patient has received all her childhood vaccinations. Received series of Hepatitis B vaccines
(date unknown). Tetanus toxoid booster vaccination received in 2010. Denies recent
flu/pneumonia vaccination.

Reproductive History
Menarche began at age of 12. Gravity: 2, Term 2, Preterm 0, Abortions 0, Living children 2.
LMP November 12, 2013. Patient premenopausal. Mother was in menopause by age 50. Denies
abnormal vaginal bleeding. No hormone therapy. Denies STD. Last Papanicolaou smear in 2013
normal. Heterosexual and has one partner. Sexually active with husband who had vasectomy.
Denies use of contraceptive and prophylactics.

Social History
Patient lives in Milledgeville and has been a nurse for many years. Currently, resides in a four
bedroom home with her husband and two male children ages 18 and 21. The family is supportive
of the patient and everyone gets along well. She attends a Christian church occasionally. The
patient denies tobacco, alcohol and illicit drug use. No recent travel or sick contacts. Her
financial situation is stable and she has medical insurance. The patient deals with stress by
reading and going to the spa. Patient has sedentary lifestyle.
Family History
No siblings.
Mother: 64 y/o, alive and well
Father: 64 y/o, alive and well
Paternal Grandmother: Deceased at 55y/o Lung cancer, COPD
Paternal Grandfather: Deceased at 60 y/o MI, HTN
Maternal Grandmother: Deceased at 65 y/o COPD, HTN
Maternal Grandfather: Deceased at 70 y/o HTN

24 Hour Diet Recall

Breakfast- Oatmeal with Apple Juice
Noon-Hamburger, French fries with a Coke
Snack-Granola bar
Dinner-Spaghetti, Garlic bread, Tossed Salad with Thousand Island dressing and Sweet Tea
Review of Symptoms

General: Denies fever, chills, malaise, weight gain/loss, and night sweats.
Skin: +Sweaty at times contributed to being premenopausal. +Surgical scars present on neck and
abdomen. Denies rash, itching, ecchymosis and open wounds.
Eyes: Denies blurred vision, diplopia, photophobia, discharge, visual changes and pain.
ENT: Denies hearing loss, vertigo, rhinorrhea, nasal obstruction or discharge, sore throat,
epistaxis, neck stiffness or tenderness, hoarseness, and dysphagia.
Respiratory: + SOB with exertion for 3 years contributed to obesity. Currently denies SOB at
this time. Denies coughing, wheezing, hemoptysis, asthma, TB
Cardiac: +Edema LLE. Denies chest pain/pressure, palpitations, orthopnea, syncope, dyspnea on
exertion
G.I.: Denies pain, nausea, emesis, constipation, diarrhea, heartburn, hematochezia, melena.
Denies any changes in stool pattern, consistency or color.
G.U.: +Urinary frequency and urgency contributed to use of diuretic. Reported symptoms
occurred once placed on Lasix. + Stress incontinence after delivery of first child. Reported
bladder damage due to birth of large infant. Denies dysuria, nocturia, discharge, hematuria
MSK: +Back pain, left knee pain, left calf pain, myalgia. Knee pain and back pain contributed to
arthritis. + Weakness in left lower extremity.
Neuro: Denies headaches, dizziness, confusion, difficulty with speech, tremors, seizures, head
injury, LOC, syncope, incoordination
Psych: Denies history of depression, anxiety, hallucinations, delusions, insomnia, suicidal
ideations, and suicide attempts
Endo: Denies heat/cold sensitivity, polydipsia, polyphagia.
Heme: Denies bruising, bleeding. No known blood or clotting disorder.

Physical Examination
Vital signs: Temp. 98.6 F, B/P 132/75, HR 80, RR 18, Sp O2 98%
General: Patient is a well-dressed, morbidly obese female sitting upright on the exam table. No
acute distress noted.
Head: Normocephalic, no masses/lesions, cicatrices
Eyes: PERRLA, conjunctiva clear, sclera white, no ptosis, red reflex present bilaterally, vessels
present w/o crossing defects, no retinal hemorrhages, visual fields intact. Vision 20/20
Ears: Tympanic membrane landmarks well visualized bilaterally. No protrusion or retractions;
Weber midline. Negative Weber and Rinne test, Whisper test 3:3. Bilateral ear piercing to lobe.
Nose: Nares patent, no deformity, septal deviation or perforation

Throat: Palate rises symmetrically, gag reflex present

Mouth: Buccal mucosa moist, pink, intact; tonsils present, dentition intact, multiple filling in
upper and lower teeth; tongue midline w/o fasciculations. Pharynx not injected, no exudates.
Uvula moves up midline.
Neck: No JVD. Thyroid not palpable. No masses. Full ROM. Trachea midline.
Nodes: No adenopathy
Chest: Breast symmetric, no retraction, lesions, masses or tenderness. No dullness to percussion.
Diaphragm moves with respiration. Diaphragmatic excursion 4 cm.
Respiratory: Respirations even, and unlabored. Symmetric chest rise and expansion. No
adventitious sounds noted. No SOB noted at this time.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmur, rubs, gallops. PMI
5th mid-clavicular ICS. No heaves, bruits or thrills. Bilateral carotid, brachial, radial, femoral,
dorsalis pedis and post tibial pulse 2+. Edema 2+ extending from left knee extending to foot.
Negative Homans sign
Spine: Moderate lordosis, mobile, nontender, no costovertebral tenderness.
Abdomen: Protuberant/convex, soft non-tender w/o masses, tympany to percussion in all four
quadrants, bowel sounds present, no bruits, no hepatosplenomegaly.
Musculoskeletal: Ambulates with a steady gait. Able to tandem walk. Negative Rhombergs
sign. Full ROM in all joints/extremities 5/5 (complete ROM against gravity with full resistance.
No muscle atrophy and masses noted. Edema extending from left knee to left foot. Positive
tenderness upon palpation of left knee bursa and calf.
Skin: Pink undertone, good turgor w/o atrophy, warm to touch, no redness or cyanosis.
Generalized macules (freckles) noted. Tattoo noted on posterior upper back, right ankle
extending to dorsal of foot and on second right toe. Scars noted on right lateral neck approx. 1.5
cm. 2 cm scars x 2 noted in RUQ of abdomen and x1 above umbilicus.
Genitalia/rectum: No lesions, inflammation or discharge from vagina. Rectum: no fissure,
hemorrhoids, fistula, or lesions in perianal area; sphincter tone good; no palpable masses,
nodules or tenderness. Stool brown. Guaiac negative.
Pelvic: Retroverted uterus, size 8 cm. No adnexal tenderness
Neurological: Awake, alert and oriented to person, place, time, and events. CN I-XII grossly
intact. Pinprick, light touch, proprioception and vibration intact. No atrophy, tremors or clonus.
RAM (rapid, alt. movement) finger to nose intact. No drift in extremities x 4. Heel to shin intact.
All deep tendon reflexes 2+ bilaterally. Naming and repetition intact; Memory 3:3. Negative
Babinski sign.
Problem List
1. Left lower extremity pain with edema
2. Shortness of breath on exertion
3. Noncompliance with medication for hyperlipidemia

4. Hypertension
5. Morbid obesity
6. Arthritis
7. Lumbosacral back pain
8. H/O Pancreatitis
9. H/O SVT during second pregnancy
10. Stress Incontinence
11. Familial history of early menopause
12. GERD
Differential Diagnosis:
Bursitis, DVT, Gastrocnemius muscle tear/strain, Shortness of Breath
Diagnosis:
Previously diagnosed with Hypertension, GERD, Hyperlipidemia, Arthritis, Morbid Obesity
Pharmacological Plan:
Continue medications as previously prescribed.
Labs:
*CBC, Renal, Magnesium, Lipid Panel, D-dimer, BNP, EKG
Radiology:
Venous ultrasonography today to rule out DVT, X-ray of left knee AP view
New medications:
Prescribe Zocor 40 mg 1 tablet PO every night (if needed) based upon lab results ordered.
Tramadol 50 mg 1 tablet PRN every 6 hours for pain. Patient instructed to discontinue use of
Ibuprofen.
Non-Pharmacologic Plan:
Weight loss counseling. Refer to PT for evaluation and treatment after DVT is ruled out. Refer to
Orthopedic physician for evaluation and treatment of left knee pain. Dietary consult for
hypertension and hyperlipidemia. Refer to Cardiology for stress test.

Education:
Patient received educational pamphlets on the effects of uncontrolled hyperlipidemia. Pamphlets
reviewed with patient. Patient educated on risk of multiple NSAIDs use and overutilization.
Given a list of common OTC NSAIDs. Patient verbalized understanding of education provided
Instructed to call office if any further questions arise.

Culture barriers/influence:
None that would interfere with medical treatment per patient.
1. Shortness of Breath with Exertion
The patient reported SOB for the last 3 years with exertion related to morbid obesity. Her
SOB may be related also to cardiac disease, and atherosclerotic changes due to
noncompliance with medication for her hyperlipidemia. Refer to cardiologist for further
evaluation.
2. DVT
Possible DVT due to sedentary lifestyle. Venous ultrasonography ordered to rule out
DVT. Based upon lab results or if positive for DVT will check for pulmonary embolus.
3. Bursitis
Positive tenderness to palpation of left knee bursa. Refer patient back to Dr. Slappy for
evaluation and treatment.
4. Gastrocnemius muscle tear/strain
The gastrocnemius muscle is at increased risk for tears/strains because it crosses to joints
the knee and ankle. Referred back to Dr. Slappy for evaluation and treatment.
Follow-up:
In 1 week to review labs/x-rays and make further recommendations. Patient informed that she
may be contacted sooner based on labs and radiology results.

Signature: ____________________________